2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

Circulation Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 e187 Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000001179 The article has been copublished with permission in Circulation and Resuscitation. A portion of this article has been reprinted with permission in Pediatrics. © 2023 The Authors. Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial NoDerivatives License, which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited, the use is noncommercial, and no modifications or adaptations are made. Circulation is available at www.ahajournals.org/journal/circ ILCOR SUMMARY STATEMENT 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces Katherine M. Berg (Chair ALS); Janet E. Bray (Chair BLS); Kee-Chong Ng (Chair PLS); Helen G. Liley (Chair NLS); Robert Greif (Chair EIT); Jestin N. Carlson (Chair FA); Peter T. Morley (Chair SAC); Ian R. Drennan (Vice Chair ALS); Michael Smyth (Vice Chair BLS); Barnaby R. Scholefield (Vice Chair PLS); Gary M. Weiner (Vice Chair NLS); Adam Cheng (Vice Chair EIT); Therese Djärv (Vice Chair FA); Cristian Abelairas-Gómez; Jason Acworth; Lars W. Andersen; Dianne L. Atkins; David C. Berry; Farhan Bhanji; Joost Bierens; Thomaz Bittencourt Couto; Vere Borra; Bernd W. Böttiger; Richard N. Bradley; Jan Breckwoldt; Pascal Cassan; Wei-Tien Chang; Nathan P. Charlton; Sung Phil Chung; Julie Considine; Daniela T. Costa-Nobre; Keith Couper; Katie N. Dainty; Vihara Dassanayake; Peter G. Davis; Jennifer A. Dawson; Maria Fernanda de Almeida; Allan R. De Caen; Charles D. Deakin; Bridget Dicker; Matthew J. Douma; Kathryn Eastwood; Walid El-Naggar; Jorge G. Fabres; Joe Fawke; Nino Fijacko; Judith C. Finn; Gustavo E. Flores; Elizabeth E. Foglia; Fredrik Folke; Elaine Gilfoyle; Craig A. Goolsby; Asger Granfeldt; Anne-Marie Guerguerian; Ruth Guinsburg; Tetsuo Hatanaka; Karen G. Hirsch; Mathias J. Holmberg; Shigeharu Hosono; Ming-Ju Hsieh; Cindy H. Hsu; Takanari Ikeyama; Tetsuya Isayama; Nicholas J. Johnson; Vishal S. Kapadia; Mandira Daripa Kawakami; Han-Suk Kim; Monica E. Kleinman; David A. Kloeck; Peter Kudenchuk; Amy Kule; Hiroshi Kurosawa; Anthony T. Lagina; Kasper G. Lauridsen; Eric J. Lavonas; Henry C. Lee; Yiqun Lin; Andrew S. Lockey; Finlay Macneil; Ian K. Maconochie; R. John Madar; Carolina Malta Hansen; Siobhan Masterson; Tasuku Matsuyama; Christopher J.D. McKinlay; Daniel Meyran; Vix Monnelly; Vinay Nadkarni; Firdose L. Nakwa; Kevin J. Nation; Ziad Nehme; Michael Nemeth; Robert W. Neumar; Tonia Nicholson; Nikolaos Nikolaou; Chika Nishiyama; Tatsuya Norii; Gabrielle A. Nuthall; Shinchiro Ohshimo; Theresa M. Olasveengen; Yong-Kwang Gene Ong; Aaron M. Orkin; Michael J. Parr; Catherine Patocka; Gavin D. Perkins; Jeffrey M. Perlman; Yacov Rabi; James Raitt; Shalini Ramachandran; Viraraghavan V. Ramaswamy; Tia T. Raymond; Amelia G. Reis; Joshua C. Reynolds; Giuseppe Ristagno; Antonio Rodriguez-Nunez; Charles C. Roehr; Mario Rüdiger; Tetsuya Sakamoto; Claudio Sandroni; Taylor L. Sawyer; Steve M. Schexnayder; Georg M. Schmölzer; Sebastian Schnaubelt; Federico Semeraro; Eunice M. Singletary; Markus B. Skrifvars; Christopher M. Smith; Jasmeet Soar; Willem Stassen; Takahiro Sugiura; Janice A. Tijssen; Alexis A. Topjian; Daniele Trevisanuto; Christian Vaillancourt; Myra H. Wyckoff; Jonathan P. Wyllie; Chih-Wei Yang; Joyce Yeung; Carolyn M. Zelop; David A. Zideman; Jerry P. Nolan; and Collaborators ABSTRACT: The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e188 include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates. Key Words: AHA Scientific Statements ◼ advanced life support ◼ cardiac arrest ◼ first aid ◼ infant ◼ newborn ◼ pediatrics Abbreviations and Acronyms ACNS American Clinical Neurophysiology Society AED automated external defibrillator AHA American Heart Association ALS advanced life support aOR adjusted odds ratio app application aRR adjusted relative risk BIS bispectral index BLS basic life support BMV bag-mask ventilation COPD chronic obstructive pulmonary disease COSCA core outcome set for cardiac arrest CoSTR International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations CPC Cerebral Performance Category CPR cardiopulmonary resuscitation CT computed tomography DSED double sequential defibrillation ECMO extracorporeal membrane oxygenation ECPR extracorporeal cardiopulmonary resuscitation EEG electroencephalogram EIT Education, Implementation, and Teams EMS emergency medical services EvUp evidence update EXACT Reduction of Oxygen After Cardiac Arrest Trial FPR false-positive rate GCS Glasgow Coma Scale GRADE Grading of Recommendations Assessment, Development, and Evaluation GWR gray-white matter ratio ICU intensive care unit IHCA in-hospital cardiac arrest ILCOR International Liaison Committee on Resuscitation IPPV intermittent positive-pressure ventilation MRI magnetic resonance imaging mRS modified Rankin Scale NfL neurofilament light NICU neonatal intensive care unit NLS neonatal life support NSE neuron-specific enolase OHCA out-of-hospital cardiac arrest OR odds ratio PAD public-access defibrillation PICO population, intervention, comparator, outcome PICOST population, intervention, comparator, outcome, study design, time frame PICU pediatric intensive care unit PLS pediatric life support PPE personal protective equipment PROSPERO Prospective Register of Systematic Reviews RCT randomized controlled trial ROC return of circulation ROSC return of spontaneous circulation S100B S100 calcium-binding protein B ScopRev scoping review SD standard defibrillation SSEP somatosensory evoked potential SysRev systematic review THAPCA Therapeutic Hypothermia After Pediatric Cardiac Arrest VABS-II Vineland Adaptive Behavior Scales Second Edition VC vector change VF ventricular fibrillation Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e189 This is the seventh in a series of annual International Liaison Committee on Resuscitation (ILCOR) International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) summary publications summarizing the ILCOR task forces’ analyses of published resuscitation evidence since ILCOR began the more continuous process of evidence evaluation in 2015. Including work from the 6 task forces, this year’s review encompasses 90 topics reviewed in some capacity, including 25 systematic reviews (SysRevs). Although only SysRevs can generate a full CoSTR and new treatment recommendations, many other topics were evaluated with more streamlined processes. Draft CoSTRs for all topics evaluated with SysRevs were posted on a rolling basis between April 2022 and January 2023 on the ILCOR website.1 Each draft CoSTR includes the data reviewed and draft treatment recommendations, with public comments accepted for 2 weeks after posting. In some cases, if requested, public comment was permitted for longer. Task forces considered public feedback and provided responses. The 25 draft CoSTR statements and scoping reviews (ScopRevs) were viewed ≈20 900 times, and 76 comments were provided. All CoSTRs are now available online, adding to the existing CoSTR statements. This summary statement contains the final wording of the treatment recommendations and good practice statements as approved by the ILCOR task forces, but it differs in several respects from the online CoSTRs: The language used to describe the evidence is not restricted to standard Grading of Recommendations Assessment, Development, and Evaluation (GRADE) terminology, making it more accessible to a wider audience; in some cases, only the high-priority outcomes are reported; the Justification and Evidence-to-Decision Framework Highlights sections are shortened in some cases but aim to provide a transparent rationale for treatment recommendations; and last, the task forces have prioritized knowledge gaps requiring future research studies. Links to the published reviews and full online CoSTRs are provided in the corresponding sections, and supporting tables and materials can be found in Appendix A. The CoSTRs are based on analysis of the data using the GRADE approach.2 SysRevs are conducted by expert systematic reviewers or by task force members, always with the involvement of ILCOR content experts. The GRADE approach that is part of this process rates the certainty of evidence that supports the intervention effects (predefined by the population, intervention, comparator, outcome [PICO] question) as high, moderate, low, or very low. Randomized controlled trials (RCTs) begin the analysis as high-certainty evidence, and observational studies begin the analysis as low-certainty evidence. Certainty of evidence can be downgraded for risk of bias, inconsistency, indirectness, imprecision, or publication bias; it can be upgraded for a large effect, for a dose-response effect, or if any residual confounding would be thought to decrease the detected effect. The format for outcome data reporting varies by the data available but ideally includes both relative risk and the absolute risk difference, both with 95% CI. The absolute risk difference is the absolute difference between the risks and is calculated by subtracting the risk in the control group from the risk in the intervention group. This absolute effect enables a more clinically useful assessment of the magnitude of the effect of an intervention and enables calculation of the number needed to treat (NNT=1/RD). In cases in which the data do not allow absolute effect estimates, alternative measures of effect such as odds ratios (ORs) are reported. Treatment recommendations are generated by the task forces after evaluating the evidence and after task force discussion. The strength of a recommendation is determined by the task force and is not necessarily tied to the certainty of evidence. Although ILCOR generally avoids providing guidance when evidence is insufficient to support a SysRev, in some cases, good practice statements have been provided for topics thought to be of particular interest to the resuscitation community. Good practice statements are not evidence-based recommendations but represent expert opinion in light of very limited data. ILCOR’s goal is to review at least 20% of all PICO questions each year so that the CoSTRs reflect current and emerging science. Acknowledging that many PICO topics will not have sufficient new evidence to warrant a SysRev, ILCOR implemented 2 additional levels of evidence review in 2020. ScopRevs are undertaken when there is a lack of clarity on the amount and type of evidence on a broader topic. Search strategies are similar in rigor to those of SysRevs, but ScopRevs do not include bias assessments or meta-analyses. The third and least rigorous form of evidence evaluation is the evidence update (EvUp), in which a minimum of a PubMed search is carried out to screen for significant new data and assess whether there has been sufficient new science to warrant a more extensive review and updated CoSTR. Both ScopRevs and EvUps can inform a decision about whether a SysRev should be undertaken but are not used to generate new or updated treatment recommendations because they do not include bias assessment, GRADE evidence evaluation, or meta-analysis. ScopRevs may be used to generate good practice statements, which represent expert opinion of the task force in light of limited evidence. In this document, ScopRevs are summarized in the relevant task force section, with references to the more complete online review. EvUps are listed at the end of each task force section in table form, with information including the prior treatment recommendation(s) related to the PICO question, how many new studies were identified, key findings, and whether an updated SysRev is recommended. Complete EvUps are provided in Appendix B. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e190 The following topics are addressed in this CoSTR summary: BASIC LIFE SUPPORT • SysRevs - Immediate resuscitation in water or on boat in drowning - Automated external defibrillator (AED) use first versus cardiopulmonary resuscitation (CPR) first in drowning - Ventilation equipment in cardiac arrest after drowning - Chest compression–only CPR in drowning - Public-access defibrillation (PAD) programs for drowning - Prehospital oxygen administration in cardiac arrest after drowning - CPR by rescuers wearing personal protective equipment (PPE) • ScopRevs - Drone delivery of AEDs • EvUps - Paddle size and placement for defibrillation - Barrier devices - Chest compression rate - Rhythm check timing - Timing of CPR cycles (2 minutes versus other) - Public access AED programs - Check for circulation during basic life support (BLS) - Rescuer fatigue in chest compression–only CPR - Harm from CPR to individuals not in arrest - Harm to rescuers from CPR - Hand position during compressions - Dispatch-assisted compression-only versus conventional CPR - Emergency medical services (EMS) chest compression–only versus conventional CPR - Compression-ventilation ratio - CPR before defibrillation - Chest compression depth - Chest wall recoil - Foreign-body airway obstruction - Firm surface for CPR - In-hospital chest compression–only CPR versus conventional CPR - Analysis of rhythm during chest compressions - Alternative compression techniques (cough, precordial thump, fist pacing) - Tidal volumes and ventilation rates - Lay rescuer chest compression–only versus conventional CPR - Starting CPR (circulation-airway-breathing versus airway-circulation-breathing) - Dispatcher recognition of cardiac arrest - Resuscitation care for suspected opioid-associated emergencies - CPR before call for help - Video-based dispatch - Head-up CPR ADVANCED LIFE SUPPORT • SysRevs - Extracorporeal CPR (ECPR) for cardiac arrest - Double sequential defibrillation (DSED) for cardiac arrest with refractory shockable rhythm - Calcium during cardiac arrest - Prognostication of favorable neurological outcome • Use of the Glasgow Coma Scale (GCS) motor score for prediction of good neurological outcome after cardiac arrest • Imaging for prediction of good neurological outcome • Use of brain injury biomarkers for the prediction of good outcome after cardiac arrest • Electroencephalogram (EEG) for prediction of good neurological outcome • Short-latency somatosensory evoked potentials (SSEPs) for prediction of good neurological outcome • EvUps - Cardiac arrest in pregnancy - Steroids after return of spontaneous circulation (ROSC) from cardiac arrest PEDIATRIC LIFE SUPPORT • SysRevs - ECPR for cardiac arrest in pediatrics - Prediction of survival with good neurological outcome after return of circulation (ROC) following pediatric cardiac arrest • Clinical examination for the prediction of survival with good neurological outcome • Blood biomarkers for the prediction of survival with good neurological outcome • Electrophysiology for the prediction of survival with good neurological outcome • Brain imaging for the prediction of survival with good neurological outcome • EvUps - Pulse check accuracy - Pad size, type, and placement for pediatric defibrillation - Antiarrhythmics for cardiac arrest with shockable rhythms at any time during CPR or immediately after ROSC - Adenosine use in supraventricular tachycardia during resuscitation - Energy doses for pediatric defibrillation Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e191 - Single or stacked shocks for pediatric defibrillation - Epinephrine frequency during CPR - Bedside ultrasound to identify perfusing rhythm - End-tidal CO2 monitoring during CPR - Invasive blood pressure monitoring during CPR - Use of near-infrared spectroscopy during cardiac arrest - Resuscitation of the pediatric patient with a single ventricle, after stage I repair - Resuscitation of the pediatric patient with singleventricle, status–post–stage III/Fontan/total cavopulmonary connection/anastomosis in cardiac arrest - Resuscitation of the pediatric patient with hemiFontan/bidirectional Glenn circulation in cardiac arrest - Resuscitation of children with cardiac arrest associated with sepsis - Fio2 titrated to oxygenation during cardiac arrest NEONATAL LIFE SUPPORT • SysRevs - Maintaining normal temperature: preterm - Heart rate monitoring: diagnostic characteristics - Exhaled CO2 detection to guide noninvasive ventilation • ScopRevs - Heart rate to initiate chest compressions - Supplemental oxygen during chest compressions - Neonatal chest compression technique (other techniques versus 2-thumb technique) - Compression-to-ventilation ratio for neonatal CPR - Use of feedback CPR devices for neonatal cardiac arrest EDUCATION, IMPLEMENTATION, AND TEAMS • SysRevs - Family presence in adult resuscitation - Stepwise approach to skills training in resuscitation • ScopRevs - Disparities in layperson resuscitation education • EvUps - Patient outcomes from team member(s) attending a CPR course - Cardiac arrest centers - Technology to summon health care professionals - Futile resuscitation rules (termination of resuscitation out of hospital) - CPR feedback devices during training - CPR self-instruction versus instructor-guided training - In situ training FIRST AID • ScopRevs - Pulse oximetry use in the first aid setting - Use of supplemental oxygen in first aid - Recognition of anaphylaxis - Potential harms from bronchodilator administration Readers are encouraged to monitor the ILCOR website1 to provide feedback on planned SysRevs and to provide comments when additional draft CoSTRs are posted. BASIC LIFE SUPPORT Out-of-Hospital Cardiac Arrest After Drowning Seven drowning questions were part of 1 large SysRev conducted by an expert review group on drowning and members of the ILCOR BLS Task Force. This SysRev was registered in International Prospective Register of Systematic Reviews (PROSPERO; CRD42021259983). A summary of the treatment recommendations for all PICO questions covered in this SysRev is given in Table 1. The same population, outcome, study design, and time frame were used for all 6 questions related to drowning. Population, Outcome, Study Design, and Time Frame • Population: Adults and children in cardiac arrest after drowning • Outcomes: - Critical: Survival to discharge or 30 days with favorable neurological outcome and survival to discharge or 30 days - Important: ROSC • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (eg, conference abstracts, trial protocols), manikin studies, narrative reviews, and animal studies were excluded. • Time frame: All years and all languages were included as long as there was an English abstract and a full-text translation was possible. The literature search was updated to April 25, 2023. Immediate Resuscitation in Water or on Boat in Drowning (SysRev) Rationale for Review This topic was prioritized by the BLS Task Force after the ScopRev3 that was completed for the 2020 Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e192 CoSTR.4,5 This SysRev was registered in PROSPERO (CRD42021259983). The full online CoSTR can be found on the ILCOR website.6 Intervention and Comparator • Intervention: Immediate resuscitation in water or on boat • Comparator: Delaying resuscitation until on land Consensus on Science One retrospective observational study (n=46) from coastal regions in Brazil was found that addressed inwater resuscitation,7 and no studies were found that addressed on-boat resuscitation. In-water ventilationonly resuscitation performed by trained lifeguards compared with resuscitation delayed to land was associated with improved survival with favorable neurological outcome (52.6% versus 7.4%; relative risk, 7.1 [95% CI,1.8–28.8]) and survival to hospital discharge (52.6% versus 16.7%; relative risk, 5.7 [95% CI, 2.3– 14.3]).7 Prior Treatment Recommendations (20058,9) In-water expired-air resuscitation may be considered by trained rescuers, preferably with a flotation device, but chest compressions should not be attempted. Individuals who are drowning should be removed from the water and resuscitated by the fastest means available. 2023 Treatment Recommendations We suggest that in-water resuscitation (ventilations only) may be delivered if rescuers trained in this technique determine that it is feasible and safe with the equipment available and the distance to land warrants its use (weak recommendation, very low–certainty evidence). We suggest that on-boat CPR may be delivered if rescuers trained in this technique determine that it is feasible and safe to attempt resuscitation (good practice statement). If the rescuers feel that the application of immediate CPR is or becomes too difficult or unsafe, then the rescuers may delay resuscitation until on land (good practice statement). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website.6 Key discussion points include the following: • Hypoxemia is the leading cause of cardiac arrest in drowning.10 Experimental and clinical data support the importance of early reversal of hypoxia as a critical intervention for improving outcomes.7,10 The logical extension of these data is to train likely rescuers to initiate resuscitation as soon as practicable (ie, either in the water or just after removal from the water, in a boat).3 Chest compressions are ineffective in water and should never be attempted.11 • In-water ventilation-only resuscitation during a rescue is feasible with proper training, sufficient rescuers, and equipment to assist with flotation.7,12–15 Survival rates similar to those achieved by Szpilman and Soares7 were reported in a case series from Australia in trained lifeguards performing in-water resuscitation in deep water.15 As identified in the ILCOR ScopRev on drowning,3 to avoid risks to the patient and themselves, rescuers Table 1. Summary of the BLS Task Force Treatment Recommendations for Drowning Resuscitation Intervention Lay rescuers BLS providers with a duty to respond EMS On-boat resuscitation On-boat CPR may be delivered if rescuers trained in this technique determine that it is feasible and safe to attempt resuscitation. If the rescuers feel that the application of immediate CPR is or becomes too difficult or unsafe, then the rescuers may delay resuscitation until on dry land. In-water resuscitation In-water resuscitation (ventilations only) may be delivered if rescuers trained in this technique determine that it is feasible and safe with the equipment available and the distance to shore warrants its use. If the rescuers feel that the application of immediate resuscitation is too difficult or unsafe, then the rescuers may delay resuscitation until on dry land. AED CPR should be started first and continued until an AED has been obtained and is ready for use. When available, an AED should be used. CPR CPR starts with compressions first.* CPR starts with ventilation first.* CPR with ventilations and chest compressions Chest compression–only CPR may be considered when ventilations are not possible. Ventilation equipment Mouth-to-mouth or pocket-mask ventilation BMV can be used by rescuers who are trained in a competency-based program with regular retraining and equipment maintenance. Follow the ALS/PLS treatment recommendations for airway management. Oxygen When available, use the highest possible inspired oxygen concentration. PAD PAD programs should be considered in aquatic environments. AED indicates automated external defibrillator; ALS, advanced life support; BLS, basic life support; BMV, bag-mask ventilation; CPR, cardiopulmonary resuscitation; EMS, emergency medical services; PAD, public-access defibrillation; and PLS, pediatric life support. *This treatment recommendation was published in the 2022 CoSTR summary.57,58 Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e193 need to consider their own safety, including the weather and water conditions, distance to land, and the availability of supportive and floating equipment and additional rescuers. Training should also include important learnings from manikin studies such as avoiding the unintentional submersion of the patient12,13,16 and the potential for fatigue and failed rescue.12,16 • The good practice statement on resuscitation in boats was informed by observational and simulation studies showing that it is feasible for rescuers trained in this technique to initiate resuscitation on moving boats.17–22 This recommendation applies to rescue boats and is not meant for the lay public. • Organizations developing guidelines from these recommendations should consider local conditions, including the type and size of the rescue vessel, the number of available rescuers, the availability of equipment and training, and the characteristics of the water and land. • For both in-water and in-boat resuscitation, the drowning expert group and the BLS Task Force emphasize the importance of continuous assessment of the safety and efficacy while performing these interventions. If either or both are compromised, rescuers should prioritize rescue and delay resuscitation until on land. Task Force Knowledge Gaps • High-quality evidence evaluating the impact of immediate (in-water ventilation and on-boat) compared with delayed resuscitation on patient outcomes, CPR quality, and rescuer safety is required. • To enable future reviews and meta-analysis, data collection should be standardized and guided by the Utstein Drowning Statement,23,24 CPR metrics recommended by the American Heart Association (AHA),25 and core outcome set for cardiac arrest (COSCA) outcomes.26,27 AED Use First Versus CPR First in Cardiac Arrest in Drowning (SysRev) Rationale for Review AED use in drowning was covered in the ILCOR ScopRev.3 The BLS Task Force prioritized 2 questions relating to AED use. This first question explored whether CPR or AED use should be prioritized in cardiac arrest after drowning. This SysRev was registered in PROSPERO (CRD42021259983). The full text of this CoSTR can be found on the ILCOR website.28 Intervention and Comparator • Intervention: AED administered before CPR • Comparator: CPR administered before AED Consensus on Science No studies were identified that addressed the population, intervention, comparator, outcome, study design, and time frame (PICOST) question. Prior Treatment Recommendations None specific to drowning 2023 Treatment Recommendations We recommend that CPR should be started first and continued until an AED has been obtained and is ready for use for adults and children in cardiac arrest caused by drowning (good practice statement). When available, we recommend an AED be used in cardiac arrest caused by drowning in adults and children (good practice statement). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website.28 Key discussion points include the following: • In 2020, the ILCOR SysRev (for cardiac arrest of all causes) found low-certainty evidence with no clear benefit for CPR before defibrillation in a meta-analysis.4,5 The 2020 recommendation of beginning with CPR first during unmonitored cardiac arrests while the defibrillator is prepared was based on a lack of new evidence since the 2015 review and the value of remaining consistent with the previous treatment recommendation.4,5 • We found no evidence that directly examined this question in the specific context of drowning. The rationale for CPR first is based on the hypoxic mechanism of cardiac arrest in drowning29 and the low incidence of shockable rhythm in drowned outof-hospital cardiac arrests (OHCAs) found in our prior ScopRev.3 Nevertheless, cardiac arrest after drowning may be a primary cardiac event in some adults and children.30 • For these reasons and because the 2021 ILCOR ScopRev on drowning did not find evidence of harm3 and AEDs are associated with improved outcomes generally,31 we recommend that an AED should be used in cardiac arrests after drowning once CPR has started. Training and guidelines should highlight the importance of drying the chest and ensuring that the patient is not in water during attempted defibrillation. Task Force Knowledge Gaps • High-quality evidence of the effectiveness of AED use on outcomes, CPR quality, and safety in drowned patients is required. • To enable future reviews and meta-analysis, data collection should be standardized and guided by the Utstein Drowning Statement,23,24 AHA-recommended CPR metrics,25 and COSCA outcomes.26,27 Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e194 Ventilation Equipment in Cardiac Arrest After Drowning (SysRev) Rationale for Review This topic was prioritized by the BLS Task Force after the ScopRev3 that was completed for the 2020 CoSTR.4,5 This SysRev was registered in PROSPERO (CRD42021259983). The full text of this CoSTR can be found on the ILCOR website.32 Intervention and Comparator • Intervention: Ventilation with equipment before hospital arrival • Comparator: Ventilation without equipment before hospital arrival Consensus on Science No studies were identified that addressed the PICOST question. Prior Treatment Recommendations None specific to drowning 2023 Treatment Recommendations We recommend using mouth-to-mouth, mouth-to-nose, or pocket-mask ventilation by BLS providers and laypeople for adults and children in cardiac arrest caused by drowning (good practice statement). We suggest that bag-mask ventilation (BMV) can be used by lifeguards or other BLS providers with a duty to respond, on the condition that it is part of a competencybased training program with regular retraining and maintenance of equipment (good practice statement). We recommend that health care professionals follow the advanced life support (ALS) treatment recommendations for airway management for adults and children in cardiac arrest caused by drowning.33,34 Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website.32 Key discussion points include the following: • In making these treatment recommendations, we considered the following indirect evidence from retrospective studies comparing airway and ventilation equipment in drowning. One study reported that the use of a supraglottic airway was associated with lower odds of survival to hospital admission compared with tracheal intubation (adjusted OR [aOR], 0.56 [95% CI, 0.42–0.76]) and lower odds of survival to discharge (aOR, 0.40 [95% CI, 0.19–0.86]) compared with BMV.35 A case study argued that an supraglottic airway might be unsuitable for drowned patients because of low lung compliance and high airway resistance.36 Two studies in children showed worse outcomes with EMS tracheal intubation of children compared with BMV (OR, 0.04 [95% CI, 0.01–0.20]37; OR, 0.25 [95% CI, 0.08–0.83]38); however, tracheal intubation is also an indicator of severity of injury in drowned OHCAs.3 • We found no evidence to suggest a change from current BLS, ALS, and pediatric life support (PLS) treatment recommendations for BLS providers, laypeople, and health care professionals.33,34,39–42 In making the conditional treatment recommendation for the use of BMV by non–health care professionals with a duty to respond such as lifeguards, the review group and BLS Task Force considered the following: that drowning resuscitation is likely to be initially performed by these groups; that there is widespread use of BMV by lifeguards in some regions, as well as a need for a BMV treatment recommendation to ensure safe practice in the use of this equipment; that work conditions (professional/ volunteer), availability of equipment, and training widely vary both between and within countries; that BMV can be difficult to perform43 and requires competency-based training, retraining, and monitoring; and that BMV equipment needs to be regularly checked and maintained. Task Force Knowledge Gaps • High-quality evidence evaluating airway and ventilation strategies on patient outcomes and CPR quality is needed. • To enable future reviews and meta-analysis, data collection should be standardized and guided by the Utstein Drowning Statement,23,24 AHArecommended CPR metrics,25 and COSCA outcomes.26,27 Chest Compression–Only CPR in Cardiac Arrest in Drowning (SysRev) Rationale for Review This topic was prioritized by the BLS Task Force after the review of CPR in drowning in the ScopRev3 that was completed for the 2020 CoSTR.4,5 This SysRev was registered in PROSPERO (CRD42021259983). The full text of this CoSTR can be found on the ILCOR website.44 Intervention and Comparator • Intervention: Chest compression–only CPR • Comparator: Conventional CPR (compressions and ventilations) Consensus on Science Two retrospective observational studies were identified that addressed the PICOST question in bystander CPR and provided very low–certainty evidence for all outcomes.45,46 There was no difference between groups in either study for survival with favorable neurological outcome or ROSC.45,46 One study45 found no difference in 30-day survival, whereas the other46 found that Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e195 conventional CPR was associated with increased survival to discharge overall (aOR, 1.54 [95% CI, 1.01–2.36]; P=0.046) and, in a post hoc subgroup analysis, documented increased odds of favorable neurological outcome in children 5 to 15 years of age (aOR, 2.68 [95% CI, 1.10–6.77]; P=0.03). Prior Treatment Recommendations None specific to drowning 2023 Treatment Recommendations For lay responders, the treatment recommendations for CPR in drowned patients with OHCA who have been removed from the water remain consistent with CPR for all patients in cardiac arrest (good practice statement). For adults, we recommend that bystanders perform chest compressions for all patients in cardiac arrest.4,5 We suggest that bystanders who are trained, able, and willing to give rescue breaths and chest compressions do so for adults in cardiac arrest.4,5 We suggest that bystanders provide CPR with ventilation for infants and children <18 years of age with OHCA.39,40 We recommend that if bystanders cannot provide rescue breaths as part of CPR for infants and children <18 years with OHCA, they should at least provide chest compressions.39,40 For health care professionals and those with a duty to respond to drowning (eg, lifeguards), we recommend providing ventilation in addition to chest compressions if they have been trained and are able and willing to do so (good practice statement). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website and the evidence-to-decision table can be found in Appendix A.44 Key discussion points include the following: • Cardiac arrest in drowning is primarily the result of a lack of oxygen in the blood.29 Therefore, providing ventilation in CPR in drowning is important. • The existing evidence, from 2 registry studies comparing conventional CPR with compression-only CPR,45,46 is at high risk of bias and is considered very low–certainty evidence. Although we acknowledge that bystanders are more willing to perform compression-only CPR, particularly on strangers,47 and compression-only CPR is well known in some regions,48 CPR with ventilations and compression in drowning is the preferred method of CPR when bystanders are capable and trained. Compression-only CPR should be considered only if ventilations are not possible. Task Force Knowledge Gaps • High-quality evidence evaluating the effect of different CPR strategies on patient outcomes is needed. Such studies should stratify by the patient’s age (adults and children) and adjust for important confounders.23,24 • To enable future reviews and meta-analysis, data collection should be standardized and guided by the Utstein Drowning Statement,23,24 AHA-recommended CPR metrics,25 and COSCA outcomes.26,27 PAD Programs for Drowning (SysRev) Rationale for Review AED use in drowning was covered in the ILCOR ScopRev.3 The BLS Task Force prioritized 2 questions relating to AED use. This second question explored PAD programs for drowning. This SysRev was registered in PROSPERO (CRD42021259983). The full text of this CoSTR can be found on the ILCOR website.49 Intervention and Comparator • Intervention: PAD program • Comparator: Absence of PAD program Consensus on Science No studies were identified that addressed the PICOST question. Prior Treatment Recommendations None specific to drowning 2023 Treatment Recommendations This treatment recommendation is unchanged from the standing recommendation for all OHCAs. We recommend implementing PAD programs for all patients with OHCA (strong recommendation, low-certainty evidence).4,5 Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website.49 Key discussion points include the following: • The BLS Task Force and review group considered that drowning often occurs in high-use public spaces where AED placement may benefit both drowning and nondrowning OHCAs. No adverse events were noted related to AED use in drowning in the ILCOR ScopRev.3 AEDs should be properly signposted—and ideally registered with EMS or in AED registries—and available and accessible for use in nearby OHCAs.50,51 We recognize that PAD programs may not be feasible to implement in lowresource settings due to associated costs for equipment, training, and maintenance. Task Force Knowledge Gaps • High-quality evidence evaluating the effectiveness of AED programs in aquatic environments on patient outcomes, CPR metrics, and safety, including their cost effectiveness, is needed. • It is unclear to what extent traditional PAD program coverage includes aquatic settings and the costbenefit ratio in these settings. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e202 Topic/PICO Year last updated Existing treatment recommendation RCTs since last review, n Observational studies since last review, n Key findings Sufficient data to warrant SysRev? BLS 373, analysis of rhythm during chest compression 2020 We suggest against the routine use of artifact-filtering algorithms for analysis of electrocardiographic rhythm during CPR (weak recommendation, very low–certainty evidence). We suggest that the usefulness of artifact-filtering algorithms for analysis of electrocardiographic rhythm during CPR be assessed in clinical trials or research initiatives (weak recommendation, very low–certainty evidence). 0 3 Three new observational studies since last SysRev Analysis during CPR leads to fewer pauses in chest compressions. High proportion of rhythms were unable to be assessed by algorithm (43%). No studies reported patient outcomes. No BLS 374, alternative compression techniques (cough, precordial thump, fist pacing) 2020 We recommend against the routine use of cough CPR for cardiac arrest (strong recommendation, very low–certainty evidence). We suggest that cough CPR may be considered only as a temporizing measure in exceptional circumstance of a witnessed, monitored IHCA (eg, in a cardiac catheterization laboratory) if a nonperfusing rhythm is recognized promptly before loss of consciousness (weak recommendation, very low–certainty evidence). We recommend against fist pacing for cardiac arrest (strong recommendation, very low–certainty evidence). We suggest that fist pacing may be considered only as a temporizing measure in the exceptional circumstance of a witnessed, monitored IHCA (eg, in a cardiac catheterization laboratory) due to bradyasystole if such a nonperfusing rhythm is recognized promptly before loss of consciousness (weak recommendation, very low–certainty evidence). We recommend against the use of a precordial thump for cardiac arrest (strong recommendation, very low–certainty evidence). 0 0 No new studies identified No BLS 546, tidal volumes and ventilation rates 2010 For mouth-to-mouth ventilation for adults using exhaled air or BMV with room air or oxygen, it is reasonable to give each breath within a 1-s inspiratory time and with an approximate volume of 600 mL to achieve chest rise. It is reasonable to use the same initial tidal volume and rate in patients regardless of the cause of the cardiac arrest. 0 0 No new studies identified No BLS 547, lay rescuer CCO-CPR vs standard CPR 2020 We continue to recommend that bystanders perform chest compressions for all patients in cardiac arrest (good practice statement). We suggest that bystanders who are trained, able, and willing to give rescue breaths and chest compressions do so for all adult patients in cardiac arrest (weak recommendation, very low–certainty evidence). 0 0 Only manikin/training studies since 2020 No new studies in 2022 No BLS 661, starting CPR (CAB vs ABC) 2020 CoSTR We suggest starting CPR with compressions rather than ventilation in adults with cardiac arrest (weak recommendation, very low–certainty evidence). 0 0 No new studies identified in 2021 or 2022 in adults No Table 3. Continued (Continued ) Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e203 ADVANCED LIFE SUPPORT ECPR for Cardiac Arrest (SysRev) Rationale for Review ECPR use continues to increase in some centers but is still not widely available. Since the last review of this topic,105 the task force was aware of 2 new RCTs. This significant addition to the body of evidence prompted the task force to update the SysRev completed for the 2019 CoSTR. The SysRev was registered before initiation (PROSPERO registration CRD42022341077).106 The full online CoSTR can be found on the ILCOR website.107 PICOST • Population: Adult (age ≥18 years) patients with cardiac arrest in any setting • Intervention: ECPR including extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass during cardiac arrest • Comparators: Manual or mechanical CPR • Outcomes: Any clinical outcome • Study designs: This was an update of the ILCOR SysRev addressing ECPR for cardiac arrest in 2018.105 New RCTs, non-RCTs, and observational studies (cohort studies and case-control studies) with a control group (patients not receiving ECPR) were included. Ecological studies, case series, case reports, reviews, abstracts, editorials, comments, letters to the editor, and unpublished studies were not included. Studies assessing cost-effectiveness were included for a descriptive overview. Studies exclusively assessing the use of extracorporeal life support for cardiac or respiratory failure after Topic/PICO Year last updated Existing treatment recommendation RCTs since last review, n Observational studies since last review, n Key findings Sufficient data to warrant SysRev? BLS 811, resuscitation care for suspected opioid-associated emergencies 2020 We suggest that CPR be started without delay in any unconscious person not breathing normally and that naloxone be used by lay rescuers in suspected opioid-related respiratory or circulatory arrest (weak recommendation based on expert consensus). 0 0 No new studies identified No BLS 1527, CPR before call for help 2020 We recommend that a lone bystander with a mobile phone should dial EMS, activate the speaker or other hands-free option on the mobile phone, and immediately begin CPR with dispatcher assistance, if required (strong recommendation, very low–certainty evidence). 0 0 No new studies identified No BLS videobased dispatch 2021 We suggest that the usefulness of videobased dispatch systems be assessed in clinical trials or research initiatives (weak recommendation, very low–certainty evidence). 2: manikin (pediatric and infant) 2 Two observational studies were identified in 2021. Of 2 new manikin RCTs in 2022, 1 reported better CPR quality with video compared with T-CPR in untrained participants but also longer times (eg, to recognition, first compression). The other reported no difference in the evaluation for foreign-body airway obstruction. No BLS headup CPR 2021 We suggest against the routine use of head-up CPR during CPR (weak recommendation, very low–certainty evidence). We suggest that the usefulness of headup CPR during CPR be assessed in clinical trials or research initiatives (weak recommendation, very low–certainty evidence). 0 2 Two new studies were identified in 2022. One observational study found no difference in survival outcomes overall and suggested improved outcomes with rapid initiation. One pilot observational study reported increased cerebral blood flow with head-up positioning during CPR. No ABC indicates airway-breathing-circulation; AED, automated external defibrillator; ALS, advanced life support; BLS, basic life support; BMV, bag-mask ventilation; CAB, circulation-airway-breathing; CCO-CPR, chest compression–only cardiopulmonary resuscitation; CoSTR, Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; CPR, cardiopulmonary resuscitation; CV, compression-to-ventilation; DSED, double sequential external defibrillation; EMS, emergency medical services; EvUp, evidence update; HBV, hepatitis B virus; IHCA, in-hospital cardiac arrest; IQR, interquartile range; OHCA, out-ofhospital cardiac arrest; PAD, public-access defibrillation; PICO, population, intervention, comparator, outcome; RCT, randomized controlled trial; RR, relative risk; SARS, severe acute respiratory syndrome; SCD, sudden cardiac death; SysRev, systematic review; T-CPR, telecommunicator CPR; and VF, ventricular fibrillation. Table 3. Continued Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e204 sustained ROSC were not included. Studies assessing extracorporeal circulation for deep hypothermia (or other conditions) were included only if cardiac arrest was documented. • Time frame: New studies published between January 1, 2018, and June 21, 2022. All languages were included if there was an English abstract. Consensus on Science Because 3 randomized trials108–110 were identified, observational studies were not considered for the updated consensus on science because of the high risk of bias. A summary of the observational studies is provided in the SysRevs.105,106 Key outcomes from the 3 included randomized trials are summarized in Table 4. One trial was stopped early for benefit after 30 patients108; 1 trial was stopped early because of slow enrollments after 15 patients109; and 1 trial was terminated early because of futility in the primary outcome, although there was an overall signal toward benefit.110 The overall certainty of evidence was rated as low because of inconsistency and imprecision and was considered very low for in-hospital cardiac arrest (IHCA) because there were no trials for IHCA. Because of a high degree of heterogeneity between the randomized trials, no meta-analyses were performed. Prior Treatment Recommendation (2019) We suggest that ECPR may be considered as a rescue therapy for selected patients with cardiac arrest when conventional CPR is failing in settings in which this can be implemented (weak recommendation, very low–certainty evidence). 2023 Treatment Recommendation We suggest that ECPR may be considered as a rescue therapy for selected patients with OHCA when conventional CPR is failing to restore spontaneous circulation in settings in which this can be implemented (weak recommendation, low-certainty evidence). We suggest that ECPR may be considered as a rescue therapy for selected patients with IHCA when conventional CPR is failing to restore spontaneous circulation in settings in which this can be implemented (weak recommendation, very low–certainty evidence). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidence-todecision table is provided in Appendix A.107 • In making this weak recommendation, we note that this patient population (ie, cardiac arrest for which conventional CPR is failing) has a very high mortality rate. Therefore, the potential for benefit and value of this intervention remains despite the overall low certainty in the evidence. • The published randomized trials have included highly selected patients for ECPR. The trial by Yannopoulos et al108 enrolled patients with OHCA with an initial shockable rhythm refractory to at least 3 shocks and randomized patients on hospital arrival. The trials by Hsu et al109 and Belohlavek et al110 enrolled patients with OHCA with any initial rhythm and randomized patients in the prehospital setting. In all 3 trials, the intervention was a treatment strategy that included ECPR. The percentages of patients in the intervention group who received ECPR were 80%, 42%, and 66% in the Yannopoulos et al, Hsu et al, and Belohlavek et al trials, respectively. The ECPR strategy in the trials by Yannopoulos et al and Belohlavek et al included immediate access to a catheterization laboratory. Guidelines for clinical practice should ideally apply to populations similar to those enrolled in the trials to date, although randomized trials have not been performed to define the optimal population. For this reason, the findings of individual trials should be interpreted cautiously in the context of the trial setting and population. Table 4. Key Outcomes by Treatment Group and Absolute Risk Difference for Patients Treated With an ECPR Strategy Compared With Standard Care Author, year n Survival to discharge/30 d, n (%) ARD (95% CI), % Favorable functional outcome* at discharge/30 d, n (%) ARD (95% CI), % Favorable functional outcome* at 6 mo, n (%) ARD (95% CI), % ECPR strategy Standard care ECPR strategy Standard care ECPR strategy Standard care Yannopoulos et al,108 2020 30 6/14 (43) 1/15 (7) 36 (7.4 to 65) 3/14 (21) 0 21 (0 to 43) 6/14 (43) 0 43 (17 to 69) Hsu et al,109 2021 15 0/12 1/3 (33) –33 (–87 to 20) 0/12 0/3 0 NA NA NA Belohlavek et al,110 2022 264 52/124 (42) 43/132 (33) 9.4 (–2.4 to 21) 38/124 (31) 24/132 (18) 13 (2 to 23) 39/124 (32) 29/132 (22) 10 (–1.3 to 20) ARD indicates absolute risk difference; ECPR, extracorporeal cardiopulmonary resuscitation; and NA, not applicable. *Favorable functional outcome defined as a modified Rankin Scale score of 0 to 3 or Cerebral Performance Category 1 or 2. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e205 • We acknowledge that ECPR is a complex intervention that requires considerable resources and training that are not universally available but also acknowledge the value of an intervention that may be successful in individuals for whom usual CPR techniques have failed. Task Force Knowledge Gaps • Few, and no large, randomized trials of ECPR compared with standard care • The optimal patient population who may benefit from ECPR • Whether subgroups of patients such as those with cardiac arrest related to pregnancy or pulmonary embolism benefit from ECPR • The optimal time to initiate ECPR in cases of refractory cardiac arrest • Whether ECPR should be initiated in the prehospital or in-hospital setting • The optimal techniques for providing safe and timely ECPR • Optimal methods for implementing ECPR programs, and quality metrics to track implementation success • The optimal post–cardiac arrest care strategy for patients resuscitated with ECPR • Population-specific differences in performing ECPR for IHCA and OHCA • Cost-effectiveness of ECPR DSED for Cardiac Arrest With Refractory Shockable Rhythm (SysRev) Rationale for Review A 2020 SysRev conducted by the ALS Task Force found no evidence of improved outcomes with the use of DSED; however, there was a recognized lack of high-quality data.111 The recent publication of an RCT prompted an update of the 2020 SysRev (registered on PROSPERO October 6, 2022). The full online CoSTR can be found on the ILCOR website.112 PICOST • Population: Adults in any setting (in hospital or out of hospital) with cardiac arrest and a shockable ventricular fibrillation (VF)/pulseless ventricular tachycardia cardiac arrest rhythm • Intervention: DSED • Comparators: Standard defibrillation (SD) strategy • Outcomes: − Critical: Survival to hospital discharge or good neurological survival at discharge or 30 days or at >30 days − Important: ROSC and survival to hospital admission − Other: Termination of VF/pulseless ventricular tachycardia • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (eg, conference abstracts, trial protocols) were excluded. All relevant publications in any language were included as long as there was an English abstract. • Time frame: Literature search for this update included studies published from February 28, 2020, to November 7, 2022. Consensus on Science We identified 1 cluster RCT, which included the pilot trial identified in the prior review.113,114 No new observational studies were identified. The cluster RCT compared DSED and vector change (VC; anteroposterior pad placement) defibrillation with SD (anterolateral pad placement) defibrillation. Therefore, this CoSTR includes the data comparing VC with SD and that comparing DSED with SD. Data were not available for adjusted statistical comparison of DSED with VC because the trial was not designed for that comparison and this post hoc analysis could not be obtained. All calculations of adjusted relative risk (aRR) were adjusted for cluster (cluster randomized trial), age, sex, and receipt of lay rescuer CPR. Unadjusted relative risk and absolute risk difference are provided in the online Grading of GRADE tables, along with the primary adjusted results.112 DSED Compared With SD A single trial114 including 261 patients with OHCA provides low-certainty evidence (downgraded for risk of bias and imprecision) for improved functional outcome (defined as modified Rankin Scale [mRS] score of 0–2) at hospital discharge with DSED compared with SD (27.4% versus 11.2%; aRR, 2.21 [95% CI, 1.26–3.88]) and improved survival to hospital discharge (30.4% versus 13.3%; aRR, 2.21 [95% CI, 1.33–3.67]). There were also an improved rate of ROSC with DSED compared with SD (46.4% versus 26.5%; aRR, 1.72 [95% CI, 1.22–2.42]) and a higher rate of termination of VF (84% versus 67.6%; aRR, 1.25 [95% CI, 1.09–1.44]). VC Defibrillation Compared With SD A single trial114 including 280 patients provides very low–certainty evidence (downgraded for serious risk of bias and very serious imprecision) of no significant improvement in favorable functional survival at discharge (defined as mRS score of 0–2) from VC compared with SD (16.2% versus 11.2%; aRR, 1.48 [95% CI, 0.81– 2.71]) and no significant improvement in ROSC (35.4% versus 26.5%; aRR, 1.39 [95% CI, 0.97–1.99]). There was improved survival to hospital discharge with VC compared with SD (21.7% versus 13.3%; aRR, 2.21 [95% CI, 1.01–2.88]) and a higher rate of termination of VF with VC compared with SD (79.9% versus 67.6%; aRR, 1.18 [95% CI, 1.03–1.36]). Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e206 Prior Treatment Recommendation (2020) We suggest against routine use of dual (or double) sequential defibrillation strategy compared with an SD strategy for cardiac arrest with a shockable rhythm (weak recommendation, very low–certainty evidence). 2023 Treatment Recommendations We suggest that a DSED strategy (weak recommendation, low-certainty evidence) or a VC defibrillation strategy (weak recommendation, very low–certainty evidence) may be considered for adults with cardiac arrest who remain in VF or pulseless ventricular tachycardia after ≥3 consecutive shocks. If a DSED strategy is used, we suggest an approach similar to that in the available trial, with a single operator activating the defibrillators in sequence (good practice statement). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidence-todecision table is provided in Appendix A.112 • Current evidence does not permit distinguishing whether either strategy (DSED or VC defibrillation) is superior to the other. • The task force discussed the importance of ensuring correct pad placement for SD before progressing to DSED or VC defibrillation and agreed with the descriptions of anterolateral pad placement provided in existing guidelines from the AHA and the European Resuscitation Council. These guidelines recommend that defibrillation pads be placed to anatomically encompass the heart (with one pad below the right clavicle, just to the right of the upper sternal border, and the other with the center of the pad in the left midaxillary line) and that adequate contact be made at the pad-skin interface so as to optimize energy delivery.115 • Double shocks require the availability of 2 defibrillators, and this has resource implications. The task force noted that DSED is already used by some EMS systems for refractory shockable cardiac arrest and therefore may be easily implemented in some systems. In other systems, this practice could require significant new resource allocation for additional defibrillators or ambulances, and the task force acknowledged that such an increase in resource allocation may not be justified on the basis of a single relatively small study. • The difference between truly refractory VF (failure to be terminated) and recurrent VF (recurring after successful defibrillation) may not be recognized clinically. Although not currently recommended for use, in the future, “see-through CPR” algorithms (enabling detection of underlying rhythm during CPR) may permit distinguishing patients with incessant refractory VF from recurrent VF after shock delivery and thus better direct electrical versus pharmacological or other therapies. • The task force discussed the concern that a single smaller-than-planned study leaves significant uncertainty about treatment effect. • The protocol used in the existing trial, with a single person providing 2 defibrillation shocks in quick succession (but not simultaneously), did not result in any reports of defibrillator damage and therefore is likely the best approach to use currently. • The importance of not equating 2 sequential shocks with a single higher-energy shock was highlighted. • Current evidence does not permit distinguishing whether the VC or the double shock using the VC in addition to SD accounts for the observed benefit. The task force had extensive discussions about whether the anteroposterior pad placement or the DSED provided most of the benefit seen. • Sensitivity analyses included in the available trial did not show a difference in outcomes with DSED when patients were analyzed by treatment received rather than intent to treat (randomization group). Reasons why certain patients received a defibrillation strategy other than that to which they were randomized are not known. Task Force Knowledge Gaps • Whether the benefit from DSED seen in this single trial will be replicated in other settings • Whether DSED is beneficial compared with changing pad placement (VC defibrillation) • The optimal timing of shock delivery when a DSED strategy is used • Whether DSED has an effect on health-related quality of life Calcium During Cardiac Arrest (SysRev) Rationale for Review Calcium has not been recommended for routine use during cardiac arrest for many years,116 but it continues to be given frequently. This topic was prioritized because of the publication of a recent RCT that adds significantly to the available evidence.117 A SysRev was conducted by members of the ALS Task Force (PROSPERO CRD4202234964).118 The SysRev included literature on adults and children. The evidence for adults was considered for this CoSTR. The full online CoSTR can be found on the ILCOR website.119 PICOST • Population: Adults with cardiac arrest in any setting • Intervention: Administration of calcium (intravenous or intraosseous) during cardiac arrest • Comparators: No administration of calcium during cardiac arrest Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e207 • Outcomes: Any clinical outcome, including ROSC, short-term survival and neurological outcomes (eg, hospital discharge, 28 days, 30 days, and 1 month), and long-term survival and neurological outcomes (eg, 3 months, 6 months, 1 year) • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) with a control group were eligible for inclusion. Ecological studies, case series, case reports, reviews, abstracts, editorials, comments, letters to the editor, and unpublished studies were excluded. • Time frame: All years and all languages were included as long as there was an English abstract. The literature search was conducted on July 8, 2022, and updated on September 31, 2022. Consensus on Science Three RCTs were identified, so because of the critical risk of bias inherent in the observational studies, only data from the 3 RCTs (one of which resulted in an additional article reporting long-term outcomes) were considered.117,120–122 The more recent and largest trial was stopped early because of concern for harm from the intervention. Key results from these trials are presented in Table 5. There were no statistically significant differences seen in any of the trials, with the exception of survival with favorable functional outcome at 90 days and 1 year in the more recent trial, with results suggesting worse outcome with calcium in both cases.117,122 All results are reported in full in the online CoSTR.119 Calcium has not been studied in the IHCA setting. Therefore, the certainty of evidence for adult IHCA was additionally downgraded for indirectness. Prior Treatment Recommendation (2010) Routine administration of calcium for treatment of IHCA and OHCA is not recommended. 2023 Treatment Recommendations We recommend against routine administration of calcium for the treatment of OHCA in adults (strong recommendation, moderate-certainty evidence). We suggest against routine administration of calcium for the treatment of IHCA in adults (weak recommendation, low-certainty evidence). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidence-todecision table is provided in Appendix A.119 Key points include the following: • This CoSTR and its SysRev focus on the routine administration of calcium during cardiac arrest in adults. • We did not identify any RCTs comparing calcium administration with no calcium administration during IHCA or for specific patient groups such as those with hyperkalemic cardiac arrest. • The trial by Vallentin et al117 was stopped early on the basis of suggestions of harm in a preplanned interim analysis, which could have increased the risk of effect size overestimation. • The risk of harm with calcium administration may depend on the scenario in which the intervention is performed. • The effect of calcium administration remains unknown for adults in cardiac arrest from special circumstances such as hyperkalemia, wide QRS interval on ECG, hypocalcemia, hypermagnesemia, calcium channel blocker overdose, or hemorrhage. Existing trials provide insufficient data on these subgroups to be able to evaluate this. • Only small trials or observational studies have attempted to stratify on the basis of initial rhythm or potassium values, and they have been limited by critical risk of bias because of confounding. Task Force Knowledge Gaps • No RCTs have evaluated calcium during IHCA. • The effect of calcium during cardiac arrest from special circumstances such as hyperkalemia, wide QRS interval on ECG, hypocalcemia, hypermagnesemia, calcium channel blocker overdose, or hemorrhage • The mechanism of harm from calcium during cardiac arrest Prognostication of Favorable Neurological Outcome (SysRev Adolopment) Rationale for Review This SysRev of prognostication after cardiac arrest (PROSPERO: CRD 420 1914 1169) was conducted by a SysRev team with involvement of content experts from the ILCOR ALS Task Force and consisted of 2 parts. The first part addressed prediction of poor neurological outcome and provided evidence for the 2020 CoSTR.123,124 The second part addressed prediction of favorable neurological outcome.125 Because the SysRev on prognostication of favorable outcome was recent and met ILCOR criteria for being of sufficient quality, the task force deemed it appropriate for adolopment. An updated search including the dates October 31, 2021, through May 20, 2022, was conducted to identify any articles published since the search for the original SysRev. This evidence was divided into several sections: GCS motor score, imaging, biomarkers, use of EEG, and SSEP. These are summarized later. Sensitivity and specificity of each modality for the prediction of favorable neurological outcome are reported for included studies. In this case, sensitivity refers to the percentage of patients with a favorable outcome who will have a positive (meaning favorable, as in a low or normal biomarker level or normal head computed tomography [CT] or EEG) test, and specificity Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e208 refers to the percentage of patients with an unfavorable outcome who will have a negative (meaning unfavorable, as in a high biomarker level or abnormal head CT or EEG) test. None of the included predictors had the <1% rate of falsely optimistic prediction that most clinicians would consider appropriate according to a survey conducted in 2019.126 However, the panel considered that achieving a 0% false-positive rate (FPR) with narrow CIs when predicting good outcome is less important than when predicting poor outcome because good outcome predictors are not used to withdraw life-sustaining treatment. Except when noted, all PICOST questions for neuroprognostication used the same PICOSTs. These are therefore listed here once and not repeated. Similarly, certainty of evidence was very low certainty for all neuroprognostication modalities included. Reasons for this are detailed in the individual online CoSTRs and not included here. Population, Comparator, Outcomes, Study Design, and Time Frame for All Neuroprognostication PICOSTs • Population: Adults (age ≥16 years) who are comatose after resuscitation from cardiac arrest (either in hospital or out of hospital), regardless of target temperature • Comparators: None • Outcomes: Prediction of good neurological outcome defined as Cerebral Performance Category (CPC) 1 or 2 or mRS score of 1 to 3 at hospital discharge or 1 month or later • Study designs: Prognostic accuracy studies for which the 2×2 contingency table (ie, the number of true/false negatives and positives for prediction of poor outcome) was reported or for which those variables could be calculated from reported data were eligible for inclusion. Unpublished studies, reviews, case reports, case series, studies including <10 patients, letters, editorials, conference abstracts, and studies published in abstract form were excluded. • Time frame: The original SysRev search was conducted on October 31, 2021, and included studies dating from 2001. The search was updated on May 20, 2022. Use of the GCS Motor Score for Prediction of Good Neurological Outcome After Cardiac Arrest (SysRev Adolopment) Intervention GCS motor score evaluated within 4 days after cardiac arrest. Consensus on Science The full online CoSTR can be found on the ILCOR website.127 The original SysRev identified 2 observational studies on the prediction of good neurological outcome using the GCS motor score (scored from 1–6, with higher scores being more favorable) on admission and within the first 4 days after cardiac arrest. No new studies were identified in the updated search. In 1 study128 including 342 patients with OHCA, a GCS motor score >3 on day 4 after cardiac arrest predicted favorable outcome at 6 months with a specificity of 84% (95% CI, 79%–88%) and a sensitivity of 77% (95% CI, 67%–85%), and a GCS motor score 3 to 5 on day 4 predicted favorable outcome with 72% (95% CI, 66%–77%) specificity and 96% (95% CI, 93%–97%) sensitivity. In 1 study129 including 302 patients with OHCA, a GCS motor score of 4 to 5 evaluated on intensive care unit (ICU) admission after cardiac arrest predicted a favorable outcome at Table 5. Selected Outcomes and Certainty of Evidence for Included Randomized Clinical Trials of Calcium During OHCA Study, year n ROSC, n (%) Survival at 30, 90, and 180 d, n (%)* Survival at 1 y, n (%) Favorable neurological outcome at 1 y, n (%) Certainty of evidence Calcium Control Calcium Control Calcium Control Calcium Control Stueven et al120 (PEA), 1985 90 8/48 (16.7) 2/42 (4.8) NR NR NR Very low† RR, 3.5 (95% CI, 0.79–15.58) Stueven et al121 (asystole), 1985 73 3/39 (7.7) 1/34 (2.9) 0 in both groups at discharge NR NR Very low† RR, 2.43 (95% CI, 0.26–22.31) Vallentin et al,117 2021, and Vallentin et al,122 2022 391 37/193 (19) 53/198 (27) 10/193 (5.2) 18/198 (9.1) 9/193 (4.7) 18/198 (9.1) 7/193 (3.6) 17/198 (8.6) Moderate‡ RR, 0.72 (95% CI, 0.49–1.03) RR, 0.57 (95% CI, 0.27–1.18) RR, 0.51 (95% CI, 0.24–1.09) RR, 0.42 (95% CI, 0.18–0.97) NR indicates not reported; OHCA, out-of-hospital cardiac arrest; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; and RR, relative risk. *Survival at all 3 time points was the same in the Vallentin et al study. †Downgraded for risk of bias and very serious imprecision. ‡Downgraded for imprecision. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e209 3 months with a specificity of 98% (95% CI, 93%–99%) and sensitivity of 12% (95% CI, 7%–17%). Prior Treatment Recommendations None (new recommendation) 2023 Treatment Recommendation We suggest assessing the GCS motor score in the first 4 days after cardiac arrest to identify patients with a score >3, which may indicate an increased likelihood of favorable outcome (weak recommendation, very low–certainty evidence). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidence-to-decision table is provided in Appendix A.127 Key points include the following: • Sedation and pain medication may influence the assessment of the GCS motor score. Waiting time after stopping such medications to achieve a reliable test result varies. • The assessment of the GCS motor score is an integral part of the identification of those unconscious patients who should undergo prognostication tests after cardiac arrest. Using the GCS motor score to identify those with a better motor response is not likely to have undesirable effects. • Any possible withdrawal of life-sustaining therapies in post–cardiac arrest patients should be undertaken only by using several prognostication modalities according to the 2020 CoSTR on the prediction of poor outcome, which includes distinct recommendations.123,124 Task Force Knowledge Gaps • Utility of GCS in post–cardiac arrest patients at various time points • Utility of the GCS motor score for patients with IHCA and those with a noncardiac cause of the arrest • How GCS motor score compares with other means of assessing prognosis, including studies assessing costs and cost-effectiveness • Value of GCS motor score in combination with other prognostic tests • Whether there is significant interrater variability between different health care professionals assessing the GCS motor score in post–cardiac arrest patients Imaging for Prediction of Good Neurological Outcome (SysRev Adolopment) Intervention Imaging studies assessed within 1 week after cardiac arrest. Outcomes CPC 1 to 3 or mRS score of 0 to 4 was accepted as an indirect outcome, in addition to the CPC 1 or 2 or mRS score of 0 to 3 used for this and other prognostication PICOSTs. Consensus on Science The full online CoSTR can be found on the ILCOR website.130 For the outcome of favorable neurological outcome, we identified 6 studies.131–136 Because of considerable heterogeneity between the studies, no meta-analysis was performed. Favorable outcome was defined as a CPC 1 or 2 or mRS score of 0 to 3 in most studies. In 1 study,135 good neurological outcome was measured as CPC 1 to 3 instead of 1 or 2. Brain CT A single study was identified by assessing the use of brain CT for prognostication of favorable neurological outcome. Key findings are summarized in Table 6, and details of the CT assessment techniques are provided in the online CoSTR and the SysRev.125 Brain Magnetic Resonance Imaging Five observational studies were identified that examined the use of magnetic resonance imaging (MRI) for prognostication of good neurological outcome.132–136 Time points of imaging ranged from 3.1 hours after ROSC to 8 days. Key study findings are summarized in Table 7. Prior Treatment Recommendations None (new recommendation) 2023 Treatment Recommendations We suggest using the absence of diffusion restriction on MRI between 72 hours and 7 days after ROSC, in Table 6. Gray-White Matter Ratio, Quantitative Regional Abnormality, and ASPECTS-b Using Brain CT: Sensitivity and Specificity for Favorable Neurological Outcome at 1 Month in a Single Study131 of CT at 1 to 3 Hours After ROSC CT variable n Timing after ROSC, min Sensitivity (95% CI), % Specificity (95% CI), % GWR >1.25 67 124.5±59.9 25 (8.7–49.1) 77 (62.0–87.7) QRA ≤567 124.5±59.9 25 (8.7–49.1) 77 (62.0–87.7) ASPECTS-b ≥15 67 124.5±59.9 75 (50.9–91.3) 89 (76.9–96.0) ASPECTS-b indicates Alberta Stroke Program Early CT Score; CT, computed tomography; GWR, gray-white matter ratio; QRA, quantitative regional abnormality; and ROSC, return of spontaneous circulation. Adapted from Sandroni et al.125 This is an Open Access article under the CC BY-NC 4.0 license. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e210 combination with other tests, for predicting good neurological outcome of adults who are comatose after cardiac arrest (weak recommendation, very low–certainty evidence). We suggest against using gray-white matter ratio (GWR), quantitative regional abnormality, and Alberta Stroke Program Early CT Score on brain CT to predict good neurological outcome in patients who are comatose after cardiac arrest (weak recommendation, very low–certainty evidence). We suggest against using apparent diffusion coefficient on brain MRI to predict good neurological outcome in patients who are comatose after cardiac arrest (weak recommendation, very low–certainty evidence). We suggest against using gradient-recalled echo on brain MRI to predict good neurological outcome in patients who are comatose after cardiac arrest (weak recommendation, very low–certainty evidence). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidence-to-decision table is provided in Appendix A.130 Key points include the following: • Evidence from 5 studies consistently suggests that the absence of visible cytotoxic edema, assessed as the absence of cortical diffusion-weighted imaging changes on brain MRI, predicts good neurological outcome with high specificity at ≥72 hours after cardiac arrest. • Apparent diffusion coefficient enables quantification of the diffusion changes on brain MRI. However, the evidence is limited to 1 study, and no apparent diffusion coefficient threshold for prediction of good neurological outcome has been established. • Evidence showing that a high GWR, a low quantitative regional attenuation score, or a high Alberta Stroke Program Early CT score predicts good neurological outcome after cardiac arrest is limited to 1 study. There is considerable heterogeneity in measurement techniques (sites and calculation methods) for GWR in the medical literature. • Evidence for GWR and gradient-recalled echo was limited to small, single-center studies. • Lack of blinding was a limitation in all included studies. • Any possible withdrawal of life-sustaining therapies in post–cardiac arrest patients should be undertaken only by using several prognostication modalities according to the 2020 CoSTR on the prediction of poor outcome, which includes distinct recommendations.123,124 Task Force Knowledge Gaps • Whether there is a consistent GWR threshold for predicting good neurological outcome after cardiac arrest • Standardization of the methods for GWR calculation, apparent diffusion coefficient calculation, and the criteria for defining an MRI as normal • The optimal timing for prognostication using brain CT after cardiac arrest • The value of serial brain CT after cardiac arrest to predict good neurological outcome Table 7. Sensitivity and Specificity of Findings on MRI—Including Diffusion-Weighted Imaging, Fluid-Attenuated Inversion Recovery, T2-Weighted Gradient-Recalled Echo, and Average Apparent Diffusion Coefficient —for Prediction of Favorable Neurological Outcome* at 6 Months Study, y n MRI measure Timing after ROSC Sensitivity (95% CI), % Specificity (95% CI), % Park et al,134 2020 36 Absence of cortical necrosis 3.1 h (2.4–4) 100.0 (86.7–100.0) 60.0 (32.3–83.7) Park et al,134 2020 36 Absence of cortical necrosis 77.6 h (75.9–80) 100.0 (86.7–100.0) 93.3 (68.1–99.8) Oh et al,133 2019 134 No diffusion restriction in cortex or deep gray matter After rewarming 72.2 (54.8–85.8) 94.9 (88.5–98.3) Oh et al,133 2019 134 No or single diffusion restriction cortex or deep gray matter After rewarming 94.4 (81.3–99.3) 91.8 (84.5–96.4) Jang et al,132 2019 39 Absence of restricted diffusion 77.6 h (75.9–80) 91.7 (61.5–99.8) 92.6 (75.7–99.1) Mlynash et al,135 2010† 33 No DWI or FLAIR lesions in cortex ≤8 d 77.8 (52.4–93.6) 80.0 (51.9–95.7) Mlynash et al,135 2010† 33 No DWI or FLAIR lesions in deep gray nuclei ≤8 d 50.0 (26.0–74.0) 86.7 (59.5–98.3) Mlynash et al,135 2010† 33 No DWI or FLAIR lesions in cerebellum and pons ≤8 d 100.0 (84.7–100.0) 20.0 (4.3–48.1) Jang et al,132 2019 39 Summary GRE score of 0 75.0 (42.8–94.5) 100.0 (89.5–100.0) Wouters et al,136 2021 58 Average ADC >931×10−6 mm2/s 5 d (IQR 4–6 d) 100.0 (86.0–100.0) 38.0 (23.0–58.0) ADC indicates apparent diffusion coefficient; DWI, diffusion-weighted imaging; FLAIR, fluid-attenuated inversion recovery; GRE, gradient-recalled echo; IQR, interquartile range; MRI, magnetic resonance imaging; and ROSC, return of spontaneous circulation. *Defined as Cerebral Performance Category 1 or 2 or modified Rankin Scale score of 0 to 3. †Favorable neurological outcome defined as Cerebral Performance Category 1 to 3 for this study. Adapted from Sandroni et al.125 This is an Open Access article under the CC BY-NC 4.0 license. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e211 Use of Brain Injury Biomarkers for the Prediction of Good Outcome After Cardiac Arrest (SysRev Adolopment) Intervention A normal or a low value for one of the following brain injury biomarkers: neuron-specific enolase (NSE), S100 calcium-binding protein B (S100B), neurofilament light chain (NfL), tau, glial fibrillary acid protein, or ubiquitin carboxy-terminal hydrolase-1 Consensus on Science The full online CoSTR can be found on the ILCOR website.137 Six observational studies were identified on biomarkers for prediction of good neurological outcome, 4 studies138–141 in the initial SysRev125 and 2 studies142,143 in the updated search. Because of considerable heterogeneity between studies, no meta-analyses were performed. Neuron-Specific Enolase NSE was investigated in 4 observational studies, including a total of 2141 patients.138–140,142 Sample acquisition ranged from 24 to 72 hours. Key results are presented in Table 8. S100B, Glial Fibrillary Acid Protein, Tau Protein, NfL, and Ubiquitin Carboxy-Terminal Hydrolase-1 Several studies were identified for other serum biomarkers to predict favorable neurological outcome. Thresholds varied across studies in many cases, as did sensitivity and specificity. An overview of findings, grouped by biomarker, is provided in Table 9. For full details, see the online CoSTR.137 Prior Treatment Recommendations None (new recommendation) 2023 Treatment Recommendations We suggest using normal NSE (<17 μg/L) within 72 hours after ROSC, in combination with other tests, for predicting favorable neurological outcome in adults who are comatose after cardiac arrest (weak recommendation, very low–certainty evidence). We suggest against using serum levels of glial fibrillary acidic protein, serum tau protein, or NfL in clinical practice for predicting favorable neurological outcome in adults who are comatose after cardiac arrest (weak recommendation, very low–certainty evidence). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidence-todecision table is provided in Appendix A.137 Key points include the following: • The best evidence is for NSE, given the number of patients included in trials and the similar thresholds used to determine a normal value across studies. • Evidence for the accuracy of the biomarkers S100B, NfL, glial fibrillary acid protein, tau, and ubiquitin carboxy-terminal hydrolase-1 is inconsistent. NfL may be more accurate, but there are few data on feasibility of measuring these novel biomarkers in regular clinical practice because all analyses have included thawed samples measured later in highly specialized laboratories. Threshold levels for predicting a good functional outcome have also varied considerably. • Any possible withdrawal of life-sustaining therapies in patients with cardiac arrest should be undertaken only by using several prognostication modalities according to the 2020 CoSTR on the prediction of poor outcome, which includes distinct recommendations.123,124 Task Force Knowledge Gaps • The utility of biomarkers in patients with IHCA and those with a noncardiac cause of arrest Table 8. Sensitivity and Specificity of NSE for Prediction of Favorable Neurological Outcome* Study, y n Threshold value, µg/L Time of acquisition, h Sensitivity (95% CI), % Specificity (95% CI), % Zellner et al,138 2013 103 <17 24 26 (15–40) 89 (77–96) 84 48 41 (25–58) 89 (77–97) Moseby-Knappe et al,139 2021 650 ≤17 24 46 (41–52) 85 (81–89) 614 48 58 (52–63) 84 (79–88) 572 72 75 (70–80) 80 (75–85) Streitberger et al,140 2017† 1053 ≤17 72 33 (29–37) 97 (95–98) Wihersaari al,142 2022‡ 248 ≤17 48 90 (85–95) 54 (44–64) NSE indicates neuron-specific enolase. *Defined as Cerebral Performance Category 1 or 2 or modified Rankin Scale score of 0 to 3 at 6 months. †Favorable neurological outcome defined as Cerebral Performance Category 1 to 3 at intensive care unit discharge in this study. ‡Outcome measured at 12 months in this study. Adapted from Sandroni et al.125 This is an Open Access article under the CC BY-NC 4.0 license. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e218 age who were comatose after IHCA were randomized to 1 of 2 targeted temperature regimens.175 In 1 secondary analysis,176 odds of survival were lower in the patients supported with ECMO (n=180) at the time of initiation of targeted temperature therapy compared with the no ECMO group (n=149; OR for survival at 12 months, 0.52 [95% CI, 0.29–0.94]; OR for survival at 12 months with Vineland Adaptive Behavior Scales Second Edition [VABS-II] score ≥70, 0.34 [95% CI, 0.17–0.67]). Another secondary analysis of the THAPCA IHCA trial compared the cognitive and neurological scores in 12-month survivors with prearrest VABS-II score ≥70 between 3 groups: those treated with ECPR (n=57), those who did not receive ECMO (n=56), and those treated with ECMO later in their course (n=14).177 VABS-II composite scores at 12 months were normal (≥70) for 39 ECPR survivors (70.9%), 47 survivors treated with no ECMO (83.9%), and 10 survivors who received later ECMO (71.4%; OR for survival with VABS-II score ≥70, 0.49 [95% CI, 0.22–1.12] in ECPR survivors compared with the other 2 groups combined). The Pediatric Resuscitation After Cardiac Arrest form was used to score conventional age-appropriate neurological examinations.178 Neurological examination scores in the none/minimal impairment to mild impairment range were observed for 28 ECPR survivors (59.5%), 33 survivors treated without ECMO (73.3%), and in 10 survivors treated with later ECMO (83.3%). Cognitive assessments were completed with the VABS-II, the Mullen scale,179 and the Weschler Abbreviated Scale of Intelligence assessment.180 Cognitive and neurological score distributions were similar between ECPR survivors and the no-ECMO and later-ECMO groups. A third study used an administrative inpatient national database in the United States to evaluate children with International Classification of Diseases, 10th Revision codes for cardiac arrest and ECMO on the same day and thus assumed to have received ECPR.181 These were compared with those with codes for a cardiac arrest only. There was no difference in mortality between patients with ECPR (cardiac arrest and same-day ECMO) and those with CPR without ECMO (59.7% versus 60.2%, OR, 0.98 [95% CI, 0.88–1.08]; P<0.681). Secondary outcomes suggest that the group with ECPR (cardiac arrest and same-day ECMO) had longer lengths of stay and higher hospitalization costs compared with those with cardiac arrest and no ECMO. A fourth study at a single center evaluated the quality of resuscitation measures with video recordings in 6 ECPR and 11 no-ECPR cardiac arrest events.182 The OR for survival to hospital discharge was reported as 0.53 (95% CI, 0.04–6.66) for the ECPR group compared with those with no ECPR. Similarly, the odds of having a Functional Status Scale183 score of 1 at hospital discharge were calculated to be 0.53 (95% CI, 0.04–6.66) for the ECPR groups compared with those with no ECPR. ECPR events were associated with lower adherence to resuscitation guidelines compared with CPR-only events. Collectively, these 4 pediatric studies favored no ECPR, but the CIs, when available, were broad, and risk of bias was assessed as critical for all studies. Treatment Recommendations (Unchanged From 2021) We suggest that ECPR may be considered as an intervention for selected infants and children (eg, pediatric cardiac populations) with IHCA refractory to conventional CPR in settings where resuscitation systems allow ECPR to be well performed and implemented (weak recommendation, very low–certainty evidence). There is insufficient evidence in pediatric OHCA to formulate a treatment recommendation for the use of ECPR. Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidence-todecision table is provided in Appendix A.174 Key discussion points included the following: • In making this weak recommendation, the PLS Task Force noted that in select pediatric patient populations (ie, cardiac arrest with cardiac disease), the practice of using ECPR has become widespread across some institutions with systems that support postoperative cardiac surgical ecosystems. • The task force acknowledges that ECPR is a complex system intervention that requires considerable resources and sustained training that may not be universally available. Task Force Knowledge Gaps • There are no comparative prospective studies or randomized trials of ECPR in children. • Whether ECPR is beneficial in selected IHCA populations (eg, noncardiac) or in OHCA populations • How the transition from conventional CPR to ECPR affects the quality of resuscitation measures • How best to provide closed-chest CPR and transition to a peripheral or central ECPR cannulation (with or without a sternotomy) or how to best perform open-chest CPR in the context of surgical instrumentation for central ECPR • How best to provide immediate and early post–cardiac arrest care with ECPR (temperature control, oxygenation, decarboxylation, perfusion pressure, transfusion therapies) • Reporting of studies using ECPR is heterogeneous and not standardized; this domain of resuscitation research would benefit from applying core definitions from the Utstein reporting standards and incorporating the pediatric COSCA.184 Moreover, an update in Utstein reporting definitions would serve to enhance the reporting of resuscitation measures applied during this technique. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e219 Prediction of Survival With Good Neurological Outcome After ROC Following Pediatric Cardiac Arrest: Combined Prognostic SysRev Rationale for Review The PLS Task Force undertook a SysRev considering the use of individual prognostic tests using clinical signs, blood biomarkers, brain electrophysiology, and brain imaging to help the clinician in predicting a good neurological outcome (PROSPERO registration CRD42021279221). For all topics, the search included studies from database inception to December 31, 2022. This assessment is different from predicting a poor neurological outcome, which may involve consideration of withdrawal of life-sustaining therapies. Recommendations for or against tests to predict good neurological outcomes cannot automatically be transferred to recommendations for poor outcome prediction, and further research is required for this purpose. The PLS Task Force defined good neurological outcome prediction as imprecise when the FPR was >30%. However, there is no universal consensus on what the acceptable limits for imprecision should be in prediction of good neurological outcome for infants and children after cardiac arrest. All evaluated tests were used in combination with other tests by clinicians in these studies. Except when noted, all PICOST questions for neuroprognostication used the same population, comparator, outcome, study design, and time frame. The timing of the intervention/diagnostic test was also the same for each. These parameters are therefore listed here once and not repeated in subsequent sections. In addition, for all topics, the available evidence had a high risk of bias based on heterogeneity across studies, few studies and patients included, lack of blinding, variation in test assessment and performance, and variability in outcome measurement. Therefore, no meta-analysis was performed, and evidence is considered very low certainty. Overall assessment of test performance was based on visual assessment of forest plots. If only 1 study was available (with small patient sample size), then a suggestion or recommendation could not be made. Population, Comparator, Outcome, Study Design, and Time Frame for All Neuroprognostication PICOSTs • Population: Children (<18 years of age) who achieve an ROC, which includes a ROSC or mechanical circulation, after resuscitation from IHCA and OHCA from any cause. Studies that included newborn infants or patients in hypoxic coma from causes without a cardiac arrest (eg, respiratory arrest, toxidromes, drowning, hanging) were excluded, except when a subpopulation of patients with cardiac arrest could be evaluated separately. • Intervention: Index prognostic tests, recorded <12 hours, 12 to <24 hours, 24 to <48 hours, 48 to <72 hours, 72 hours to <7 days, or 7 to 10 days after cardiac arrest • Comparator: There was no control group for intervention/exposure. The accuracy of the prognostic index test was assessed by comparing the predicted outcome with the final outcome, which represents the comparator. • Outcome: Prediction of survival with good neurological outcome defined as a Pediatric CPC score of 1, 2, or 3 or VABS-II score ≥70 at the pediatric ICU (PICU) or hospital discharge, 1 month or later. • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Case series were considered if >5 cases were reported. Unpublished studies (eg, conference abstracts, trial protocols) and animal studies were excluded. We selected studies for which the sensitivity and FPR of the prognostic (index) test were reported. • Time frame: All years and all languages were included if there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols) were excluded. The search was initially run on February 17, 2022, and was updated December 31, 2022. Clinical Examination for the Prediction of Survival With Good Neurological Outcome Intervention: Includes every part of a bedside neurological clinical examination, including pupillary response (assessed using manual light reflex or automated pupillometry), level of coma (eg, GCS score or Full Outline of Unresponsiveness score), and brainstem reflexes. Consensus on Science See the ILCOR website for the full online CoSTR.185 Pupil Reactivity The predictive ability of presence of pupil reactivity to classify good neurological outcome was evaluated in 8 studies186–193 in 402 patients within 1, 6 to 12, 24, and 72 hours after resuscitation. Most studies had a sensitivity >82% at all assessment times, and the corresponding FPR ranged from 3.2% to 67%. Within 12 hours of ROC, the FPR was <33% in 3 of 4 studies reporting this time period.187,188,191 FPR increased to 38% to 68% at 24 to 72 hours, and the corresponding sensitivity for predicting good neurological outcome was 100% at 48 to 72 hours after ROC.186,190 No studies evaluated automated pupillometer monitoring devices. Coma Level The relationship between coma assessment using the GCS motor score alone or total GCS and good neurological Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e220 outcome at ICU discharge, hospital discharge, and 6 months was evaluated in 3 studies191,193,194 including 296 patients. In 1 study, GCS motor score of ≥4 within 1 hour and at 4 to 6 hours after ROC had a sensitivity of 17% and 50% for predicting good neurological outcome at 6 months, with a corresponding FPR of 6% and 7%, respectively.191 When total GCS measured at resuscitation or within 1 hour was used, a score of ≥5 predicted good neurological outcome with a low sensitivity of 30% and an FPR of 14%.194 A total GCS score of ≥8 had a slightly higher sensitivity of 31%, with a low FPR of 6%.193 However, only 1 study was available to assess each test using total GCS or GCS motor score cutoff or at each testing time point. Motor Response The presence of a motor response to any stimulus was evaluated in 1 study186 at <1, 48, and 72 hours after ROC with up to 27 patients. Sensitivity and FPR improved with time. At <1 hour after ROC, the sensitivity was 38% and FPR was 30%; in comparison, at 72 hours, the sensitivity was 100% and the FPR was 23%. Brainstem Reflex The presence of brainstem reflexes to predict good neurological outcome at ICU or hospital discharge was evaluated in 2 studies188,192 including 118 patients. Evoked responses to pain, gag reflex, and cough reflex were assessed at 6 to 12 hours and at 24 hours. Predictive sensitivity of presence of pain response at 6 to 12 hours was 100% with an FPR of 67%.188 The presence of both a gag and cough reflex at 24 hours predicted a good neurological outcome with a sensitivity of 40% and FPR of 32% to 35%.192 Prior Treatment Recommendations (2015) We suggest that practitioners use multiple variables when attempting to predict outcomes for infants and children after cardiac arrest (weak recommendation, very low–quality evidence). There was no previous recommendation for the use of clinical examination. 2023 Treatment Recommendations All evaluated tests were used in combination with other tests by clinicians in these studies. Although the predictive accuracy of tests was evaluated individually, we recommend that no single test should be used in isolation for prediction of good neurological outcome (good practice statement). We suggest using pupillary light reflex within 12 hours after ROC for predicting good neurological outcome in children after cardiac arrest (weak recommendation, very low–certainty evidence). We cannot make a recommendation for or against using total GCS, GCS motor score, or motor response after ROC for predicting good neurological outcome in children after cardiac arrest. We cannot make a recommendation for or against the use of brainstem tests after ROC for predicting good neurological outcome in children after cardiac arrest. Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidence-todecision table is provided in Appendix A.185 Key points include the following: • For pupillary light reflex, limited evidence suggests that the specificity for prediction of good neurological outcome was highest within 12 hours of ROC after cardiac arrest. There was increased sensitivity (up to 100%) for predicting good outcomes at 48 to 72 hours; however, the point estimates had wide CIs. Pupillary light reflex at 48 to 72 hours should be evaluated for use in predicting poor neurological outcome at these times. • For all clinical examination modalities, inaccuracy of outcome prediction tests may be due to confounding from the effect of sedatives. No studies reported any assessment of the confounding influence of medication or specifically excluded the presence of residual sedation at the time of clinical examination. • No studies included blinding of test results from treating clinicians, and only 1 study had blinded outcome assessment (for pupil light reactivity). Lack of blinding is a major limitation of clinical examination tests, even if the withdrawal of life-sustaining therapy based on clinical examination has not been documented in any of the studies included in our review. • The studies inconsistently reported the cointervention of temperature control on the clinical assessments. • Despite the limitations of the assessment of pupil light reactivity and coma assessment, the balance between the costs and benefits favors benefit. Task Force Knowledge Gaps • Clinical examination for prognostication after cardiac arrest appears promising, but more research is required in infants and children. • The impact of residual medication or temperature on pupillary light reflex assessment, coma score, and motor response in infants and children • The cost and benefits of the use of pupillometry compared with pupillary light reflex assessment • Economic cost evaluation and cost-effectiveness studies are required. • Further research is required on multimodal prognostication, timing, definitions of testing, accurate outcome timing, and outcome definition. • A better understanding of survivorship after pediatric cardiac arrest—informed by wider research and consultation with patients, children, parents, Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e221 guardians and caregivers, health care professionals, and members of the wider society—is needed to inform correct definitions and a framework of good neurological outcome for prediction research. Blood Biomarkers for the Prediction of Survival With Good Neurological Outcome Intervention: Serum biomarkers specific to neuronal damage (eg, NSE, S100B, glial fibrillary acidic protein, NfL) or blood markers of inflammation or systemic ischemic reperfusion (eg, procalcitonin, blood pH, or lactate) Consensus on Science See the ILCOR website for the full online CoSTR.195 Lactate Lactate was evaluated in 5 studies.175,196–199 Three studies documented <7% FPR for lactate <2 mmol/L at <1 hour and at 6 to 12 hours,175,197,199 although the sensitivity in these studies was low (16%–28%). Lactate <2 mmol/L at 24 to 48 hours was sensitive (69%–86%) for good neurological outcome; however, the FPR was high at 61% and 68%. Lactate <5 mmol/L at <1 hour had moderate sensitivity (66%) and FPR (62%) and at 24 hours had high sensitivity (89%) and low FPR (17%), making the latter a useful test for prediction. Lactate clearance over 48 hours to <2 mmol/L had a high sensitivity (100%) and high FPR (77%). pH pH was evaluated in 4 studies.175,196,197,199 pH thresholds were >7.0, >7.3, and <7.5 at resuscitation and within 1, 6 to 12, and 24 hours of ROC. The blood pH measured after resuscitation or <1 hour from ROC had a wide range of sensitivities of 27% to 95% for predicting good neurological outcome. A pH >7.0 was reported in 3 studies and had a 68% to 98% sensitivity to predict survival and 71% to 97% sensitivity for good neurological outcome. FPR for good neurological outcome was >80% for all except for pH threshold >7.0 at <1 hour after ROC (FPR, 45%) and >7.3 at <1 hour after ROC (FPR, 38%). Neuronal Biomarkers Only 1 study including 43 children reported NSE, S100B, and myelin basic protein values.190 Threshold values were calculated and reported to classify either high sensitivity or low FPR for good neurodevelopmental outcome. At 24 hours, an S100B value of 0.128 ng/mL predicted a good neurodevelopmental outcome with a sensitivity of 100%, with a moderately high FPR of 62%. Sensitivity was high (100%) for predicting good outcome with an NSE threshold of 53.1 ng/mL at 24 hours and 76.7 ng/ mL at 48 hours (with a corresponding FPR of 81% and 77%, respectively). Myelin basic protein level of 5.83 ng/ mL at 24 hours and 5.43 ng/mL at 48 hours also had a high predictive sensitivity of 100% but high FPR of 96% and 88%, respectively. Lower threshold values of S100B (0.001 ng/mL at 24 hours), NSE (0.48 ng/mL at 48 hour), or myelin basic protein (0.05 ng/mL at 48 hours) had a sensitivity of 6% to 29% with a corresponding very low FPR of <6% for good neurological outcome. Studies evaluating additional neuronal biomarkers (eg, glial fibrillary acidic protein, ubiquitin carboxyl-terminal hydrolase-L1, NfL, and tau) in children after cardiac arrest with good and poor outcomes were identified,200–203 but we were unable to calculate the sensitivity and specificity from the raw data available in the published articles. Prior Treatment Recommendations No previous recommendations for the use of specific biomarkers 2023 Treatment Recommendations All evaluated tests were used in combination with other tests by clinicians in these studies. Although the predictive accuracy of tests was evaluated individually, we recommend that no single test should be used in isolation for the prediction of good neurological outcome (good practice statement). We suggest using a normal plasma lactate value (<2 mmol/L) up to 12 hours after ROC for predicting good neurological outcome of children after cardiac arrest (weak recommendation, very low–certainty evidence). We cannot make a recommendation for or against using time to lactate clearance within 48 hours after ROC for predicting good neurological outcome. We suggest against using pH after ROC for predicting good neurological outcome after cardiac arrest (weak recommendation, very low–certainty evidence). We cannot make a recommendation for or against the use of blood neuro-biomarkers (eg, S100B NSE) after ROC for predicting good neurological outcome in children after cardiac arrest. Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidenceto-decision table is provided in Appendix A.195 Key points include the following: • Lactate and pH are potential markers of ischemia, poor perfusion, and anaerobic metabolism and are known to be associated with poor outcomes after cardiac arrest. Lactate metabolism is complex, and consideration of confounders and other predictors is critical. • Included studies were observational studies and RCTs, but they were not designed primarily to test prognosis of blood biomarkers. • Lactate is measured by blood gas analyzers and is easily accessible. Considering the low (but not Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e222 negligible) cost of testing lactate and pH, a problem of inequity is unlikely but possible. Lactate and blood pH are widely available in settings with ICUs, but many settings do not have ICUs. • Only 1 study190 has identified threshold values for 2 blood neuronal biomarkers (S100B and NSE) that are associated with good neurological outcome with a high sensitivity. However, the FPR is high, and these tests require specialized laboratory equipment and are not widely available. • No studies reported any assessment of the confounding influence of medication. • No studies included blinding of test results from treating clinicians, and only 1 study had blinded outcome assessment. Lack of blinding is a major limitation of biomarker tests, even if the withdrawal of life-sustaining therapy on the basis of test results was not documented in any of the studies included in our review. Task Force Knowledge Gaps • The utility of other candidate biomarkers (eg, NfL, glial fibrillary acidic protein, tau, ubiquitin carboxylterminal hydrolase-L1) and whether subgroups may exist in which the FPR is much lower • Cost-effectiveness of biomarker testing • Further research is required on multimodal prognostication, timing, definitions of testing, accurate outcome timing, and outcome definition. • A better understanding of survivorship after pediatric cardiac arrest—informed by wider research and consultation with patients, children, parents, guardians and caregivers, health care professionals, and members of the wider society—is needed to inform correct definitions and framework of good neurological outcome for prediction research. Electrophysiology for the Prediction of Survival With Good Neurological Outcome Intervention: Surface bioelectrical recordings from the central nervous system such as EEG and evoked potentials (eg, brainstem auditory-evoked potentials, and short-latency SSEPs). We included studies of the interpretation of raw signals or summary measures derived from processed EEG signals such as amplitude-integrated EEG, quantitative EEG, or BIS. Consensus on Science The full online CoSTR can be found on the ILCOR website.204 Absence of Clinical or Electrographic Seizure Twelve studies reported the relationship between absence or presence of seizures in children after cardiac arrest and good neurological outcomes at PICU/hospital discharge, 6 months, and 12 months.175,188,189,191,198,199,205–210 These studies included 1165 children, and 4 of the 12 studies reported using the ACNS criteria.189,205,208,210 Absence of seizures up to 24 hours after ROC had a sensitivity of 50% to 100% with an FPR of 63% to 98% for predicting good neurological outcome at various time points.191,205,208,209 Absence of seizure after 24 hours had a sensitivity of 50% to 100% with an FPR of 42% to 100% for predicting good neurological outcome.175,188,189,191,198,199,202,208,210 Absence of Status Epilepticus Absence of status epilepticus was reported in 3 studies.205,209,210 Two of these studies used ACNS criteria to define status epilepticus. Good neurological outcome at PICU/hospital discharge was predicted with a high sensitivity of >90%, although the FPR remained high at 81% to 91%. Absence of Myoclonic Epilepsy On the basis of 2 studies, absence of myoclonic seizures predicted good neurological outcomes with a sensitivity of 100% but a very high FPR of 79% to 83% at PICU/ hospital discharge.188,208 Somatosensory Evoked Potentials SSEPs, evaluating the presence or absence of N20 waves, were reported in only 1 study, with few patients (n=12) reporting good neurological outcome (Pediatric CPC score 1 to 3) at 3 times (24, 48, and 72 hours).211 Clinicians were blinded to test results, and the SSEP assessor was blinded to outcome. The sensitivity for prediction of good neurological outcome was 100% at 24 and 48 hours and 83% at 72 hours, with a very low FPR of 0% at all time points but wide 95% CIs (0%–71%). Presence of Continuous or Normal EEG Background The presence of a normal EEG background (defined as normal, continuous and reactive, continuous and unreactive, and nearly continuous by ACNS definitions) was reported in 10 studies with 18 different testing timings and included 563 patients (although there was a risk of overlapping patient populations).188–190,192,205,206,208–210,212 Studies using normal or continuous EEG reported a low to moderate sensitivity of <50% at 10 of 18 testing times for predicting good neurological outcome. However, the FPR was also low (<50% in all cases and <30% in 11/18). In the largest study,209 the sensitivity of continuous EEG at 6 to 12 hours was 7.3% with an FPR of 0%. The FPR was higher in studies assessing prognostic accuracy at and beyond 48 hours after ROC. Absence of Attenuated, Isoelectric, or Flat EEG Background The absence of an attenuated, isoelectric, or flat EEG was reported in 10 studies including up to 526 patients (although there was a risk of overlapping patient populations).188–190,192,205,206,208–210,212 The sensitivity to predict a Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e223 good neurological outcome was very high in 8 studies (91%–100%)188,189,192,202,205,208,209,212; however, there was a wide range of FPR of 0% to 83%, with the majority of studies reporting >40% FPR. Absence of Burst Suppression, Burst Attenuation, or Generalized Periodic Epileptiform Discharges on EEG Absence of burst suppression, burst attenuation, or generalized periodic epileptiform discharges was reported in 6 unblinded studies including 395 patients.188,192,205,208–210 Sensitivity increased from 81% to 100% within 6 to 12 hours, to a highly sensitive test (100% with high precision [95% CI, 100%–100%]) at 24, 48, and 72 hours. However, the FPR was high at all time periods (67%–100%) for predicting a good neurodevelopmental outcome. Presence of a Reactive EEG The presence of reactivity within an EEG was reported in 3 studies, with a moderate sensitivity for good neurological outcome of 53% to 80% between 6 and 72 hours.192,208–210 The FPR ranged from 7% to 27% up to 24 hours after ROC in 2 studies.192,208 However, it increased to 50% at 48 hours after ROC in 1 study. Presence of Sleep II Architecture or Sleep Spindles on EEG The presence of sleep II architecture or sleep spindles was reported in 2 studies including 123 patients at 6 to 12 hours and 24 hours following ROC after cardiac arrest. The presence of these features had a predicted sensitivity of 57% to 80% and low FPR (8.3%–16%).189,192 Presence of EEG Variability and EEG Voltage Variability EEG variability, defined with ACNS criteria, had a moderate sensitivity for predicting good outcome (60%–80%) in 2 studies of 132 patients, with a corresponding FPR of 18% to 50%.192,208 However, EEG voltage variability had a higher sensitivity (75%–100%) in 1 study at all measured time points (6–12, 24, and 48 hours after ROC) and a higher corresponding FPR of 36% to 67%.208 Quantitative EEG Scoring Only 1 study reported a composite score assessing EEG background from a 24-hour monitoring period, obtained from quantitative EEG using the amplitude integrated EEG trace in 30 patients.213 A score of >15 had a predicted sensitivity of 94% and FPR of 67% for a good neurological outcome. Prior Treatment Recommendations (2015) We suggest that the use of EEG within the first 7 days after pediatric cardiac arrest may assist in prognostication (weak recommendation, very low–quality evidence). 2023 Treatment Recommendations All evaluated tests were used in combination with other tests by clinicians in these studies. Although the predictive accuracy of tests was evaluated individually, we recommend that no single test should be used in isolation for prediction of good neurological outcome (good practice statement). We suggest using EEG within 6 to 72 hours after ROC for predicting good neurological outcome in children after cardiac arrest (weak recommendation, lowcertainty evidence). We suggest using the following EEG features after ROC for predicting good neurological outcome: presence of sleep spindle and sleep II architecture at 12 to 24 hours, continuous or normal background EEG between 1 and 72 hours, or EEG reactivity between 6 and 24 hours (weak recommendation, very low–certainty evidence). We suggest against using the following EEG features after ROC to predict good neurological outcome: absence of clinical or electrographic seizures; absence of status epilepticus; absence of myoclonic epilepsy; absence of burst suppression, burst attenuation, or generalized periodic epileptiform discharges; or absence of attenuated, isoelectric, or flat EEG (weak recommendation, very low–certainty evidence). We cannot make a recommendation for or against the use of the presence or absence of N20 response SSEPs after ROC for predicting good neurological outcome. We cannot make a recommendation for or against the use of EEG variability, EEG voltage, or quantitative EEG score for predicting good neurological outcomes. Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidenceto-decision table is provided in Appendix A.204 Key points include the following: • ACNS definitions for seizures and EEG indices were followed in only some studies. EEG and SSEP prognostic criteria require clear and reproducible definitions and require validation in the PICU environment. • The complex interpretation of normality in background EEG patterns in preterm and term infants and the impact of brain maturation on EEG patterns in infancy and childhood require expert neurophysiology input. Studies reported limited information on the handling of this area, and further refinement of definitions and application of recommendation is required. • There was limited or no accounting for when tests were undertaken in relation to concurrent pharmacological exposure, sedation, and ongoing treatment (eg, targeted temperature management) in patients after cardiac arrest. • SSEPs have a high level of precision in adult studies of neuroprognostication in comatose patients after cardiac arrest. The PLS Task Force recognizes the lack of available data in children and strongly encourages further multicenter evaluation. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e224 Task Force Knowledge Gaps • Electrophysiology tests for prognostication after cardiac arrest appear promising, but more research is required in infants and children. • The type of monitoring (intermittent or continuous EEG, use of reduced channel monitoring, quantitative EEG systems), duration of monitoring, and timing of prognostic assessment • Validation of ACNS or other international definitions of EEG indices within the PICU environment for infants and children after cardiac arrest • Further work is needed on multimodal prognostication, timing, definitions of testing, accurate outcome timing, and definition. • A better understanding of survivorship after pediatric cardiac arrest—informed by wider research and consultation with patients, children, parents, guardians and caregivers, health care professionals, and members of the wider society—is needed to inform correct definitions and framework of good neurological outcome for prediction research. Brain Imaging for the Prediction of Survival With Good Neurological Outcome Intervention: Neuroimaging modalities included head CT, brain MRI, cranial ultrasound, or transcranial Doppler ultrasound. Consensus on Science See the ILCOR website for the full online CoSTR.214 CT Imaging Head CT to predict good neurological outcome (Pediatric CPC 1–3) was evaluated in 3 studies including 173 patients.190,210,215 The majority of CT imaging was acquired at 24 or 48 hours after the cardiac arrest. Neurological outcome was assessed on discharge from the ICU or hospital in 2 studies and at 6 months in 1 study. Reported factors from CT included presence and absence of intracranial hemorrhage, cerebral edema or ischemia measured by the reversal sign, gray-white matter differentiation, and sulcal or basal cistern effacement. Two studies described methods of estimating gray-white matter differentiation,215,216 and 2 studies reported radiologists’ qualitative reports.190,215 The presence of gray-white matter differentiation on CT at 24 hours had a sensitivity of 64% to 100% and an FPR of 35% to 70%. Absence of CT lesions, edema, or intracranial hemorrhage predicted good neurological outcome with a sensitivity ranging from 72% to 100%; however, a wide range of FPR (14%–90%) was reported. Absence of effacement of sulci or basal cisterns predicted good neurological outcome with a high sensitivity (93%–100%) and an FPR 32% to 73%. Clinicians were not blinded to the CT results in any study. Magnetic Resonance Imaging MRI to predict good neurological outcomes was reported in 4 studies including 215 patients.206,217–219 Median time from ROC to MRI ranged from 3 to 6 days across all studies, although inclusion of patients’ MRIs up to 14 days was reported in 3 studies.206,217,219 Two studies reported the presence or absence of abnormalities in multiple regions of the brain in 3 sequences (diffusion-weighted imaging, T1, and T2).217,218 Another study presented a composite of presence or absence of 1 (or more) region of abnormality.206 One study evaluated thresholds of apparent diffusion coefficient and overall qualitative MRI reporting of evidence of hypoxic ischemic injury.219 Three studies ensured that the neuroradiologist’s MRI assessment was blinded to patient clinical status. However, the MRI findings were known by the treating clinicians, and neurological outcome assessment was not blinded.206,217,218 Absence of any region of abnormality on restricted diffusion at a median of 4 days after ROC predicted good neurological outcome with a sensitivity of 88% and corresponding very low FPR of 2% in 1 study.206 Apparent diffusion coefficient threshold >600×10-6 mm2/s in >93% and >650×10−6 mm2/s in >89% of brain volume at a median of 4 days after ROC predicted good neurological outcome with a sensitivity of 100% and a low FPR (20%).219 In the same study, a normal MRI by qualitative reporting of absence of hypoxic ischemic injury predicted a good neurological outcome at 6 months with a sensitivity of 81% and an FPR of 10%.219 For individual regions of the brain, at 4 to 6 days after ROC, diffusion-weighted imaging MRI sequence had a sensitivity for predicting good neurological outcome ranging from 67% to 100%, although associated FPR rates were moderate to high. Absence of lesions in the lentiform regions on T2-weighted imaging had a sensitivity of 67% and the lowest FPR (7.7%) for any single region of the brain. Transcranial Doppler Ultrasound The prediction of good neurological outcome using presence of flow velocities of intracranial vessels measured on transcranial Doppler was evaluated in 1 study including 17 patients who were treated with hypothermic targeted temperature management.220 Flow patterns without any reversal (or absence of diastolic) flow, mean flow velocity, and pulsatility index were assessed before, during, and after hypothermia therapy. Continuous-flow velocities without reversal of diastolic flow pattern had a sensitivity of 100% and an FPR of 44%. Within 1 hour of the event in the prehypothermia phase, mean flow velocity had a sensitivity for good neurological outcome of 38% and an FPR of 0%, and having a normal pulsatility index had a sensitivity of 38% and an FPR of 22%. In the hypothermia phase, mean flow velocity had a sensitivity of 25% and an FPR of 11%; pulsatility index had a higher sensitivity of 100% and an FPR of 22%. By 72 Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e225 hours, normal pulsatility index predicted a good outcome, with 88% sensitivity and 11% FPR. Clinicians were not blinded to the transcranial Doppler results in this study. Cranial Ultrasound We identified no studies examining the role of cranial ultrasound and good neurological outcome after cardiac arrest in children. Prior Treatment Recommendations No previous recommendations for the use of brain imaging 2023 Treatment Recommendations All evaluated tests were used in combination with other tests by clinicians in these studies. Although the predictive accuracy of tests was evaluated individually, we recommend that no single test should be used in isolation for prediction of good neurological outcome (good practice statement). We suggest against using normal CT imaging at 24 to 48 hours from ROC for predicting good neurological outcome (weak recommendation, very low–certainty evidence). We suggest using normal MRI between 72 hours and 2 weeks after ROC for predicting good neurological outcome (weak recommendation, low-certainty evidence). We cannot make a recommendation for or against the use of transcranial Doppler ultrasound for predicting good neurological outcome. Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidence-todecision table is provided in Appendix A.214 Key points include the following: • The low FPR (high specificity) for normal MRI on global assessment for predicting good neurological outcome reduces the chance of false optimism if a normal MRI predicts a good neurological outcome. • The sensitivity of a normal MRI or CT to predict a good neurological outcome is moderate to high, but up to 30% may be falsely categorized, and a falsely pessimistic prediction may be made. Therefore, with the very low–certainty evidence, we cannot make a recommendation for or against the use of normal or abnormal MRI or CT for predicting poor neurological outcomes. • The precision of MRI and CT is affected by the timing of the acquisition of the image; images may be unrevealing if obtained outside the window of peak cellular edema and ischemia. • The definition of presence or absence of injury on diffusion-weighted imaging or threshold values for apparent diffusion coefficient on MRI or GWR on CT was inconsistent in the included studies. • Both MRI and CT are expensive tests and require specialist equipment, training, interpretation, and, most often, patient transport to obtain the information. This may be prohibitive in physiologically unstable patients or some health care settings. Task Force Knowledge Gaps • Neuroimaging for prognostication after cardiac arrest appears promising, but more research is required in infants and children. • A standardization of definitions and assessment of optimal thresholds for GWR calculation on CT and diffusion-weighted imaging and apparent diffusion coefficient thresholds on MRI is needed. • The optimal timing for prognostication with CT and MRI after cardiac arrest needs to be determined; studies assessing serial imaging after cardiac arrest are desirable. • The role of assessing regional areas of the brain for predicting outcome or the use of magnetic resonance spectroscopy • Cost-effectiveness of CT and MRI for prognostication • Further work is needed on multimodal prognostication, timing, definitions of testing, and accurate outcome timing and definition. • A better understanding of survivorship after pediatric cardiac arrest—informed by wider research and consultation with patients, children, parents, guardians and caregivers, health care professionals, and members of the wider society—is needed to inform correct definitions and framework of good neurological outcome for prediction research PLS Topics Reviewed by EvUps Topics reviewed by EvUps are summarized in Table 16, with the PICO, existing treatment recommendation, number of studies identified, key findings, and whether a SysRev was deemed worthwhile provided. Complete EvUps can be found in Appendix B. NEONATAL LIFE SUPPORT Maintaining Normal Temperature: Preterm (SysRev) Rationale for Review A previous SysRev conducted for ILCOR concluded that there was a dose-responsive association between hypothermia on admission to a neonatal unit or postnatal ward and increased risk of mortality and other adverse outcomes.221 These findings are supported by more recent large observational studies.222,223 A SysRev estimated that hypothermia was common among infants born in both hospitals and homes, even in tropical environments.224 A SysRev was initiated from a priority list from the ILCOR Neonatal Life Support (NLS) Task Force (PROSPERO Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e226 Table 16. PLS Topics Reviewed by EvUps Topic/PICOST Year last updated Existing treatment recommendation RCTs since last review, n Observational studies since last review, n Key findings Sufficient data to warrant SysRev? Pulse check accuracy 2020 The ILCOR treatment recommendations from 2020 remain unchanged: Palpation of a pulse (or its absence) is not reliable as the sole determinant of cardiac arrest and need for chest compressions. If the individual is unresponsive or not breathing normally and there are no signs of life, lay rescuers should begin CPR. In infants and children with no signs of life, health care providers should begin CPR unless they can definitely palpate a pulse within 10 s. 0 0 In the 2020 EvUp on the accuracy of pulse check in detecting ROC after cardiac arrest in children, 2 studies were identified describing the use of manual pulse check in pediatric cardiac arrest. Our EvUp in 2022 identified several adult studies assessing the utility of manual pulse palpation at different sites and manual pulse palpation vs other innovative techniques such as arterial Doppler ultrasound, POCUS, photoplethysmography, and ECG-based pulse detection. However, no new pediatric studies were identified. Despite several recent adult studies comparing manual pulse palpation with other methods of detecting ROC after arrest, there remains very little pediatric-specific evidence in this area. No Pad size, type, and placement for pediatric defibrillation 2020 The ILCOR treatment recommendations remain unchanged: There is insufficient evidence to alter the current recommendations to use the largest size paddles that fit an infant’s or child’s chest without touching each other or to recommend one paddle or pad position or type over another. Either self-adhesive defibrillation pads or paddles may be used in infants and children in cardiac arrest. 0 0 In the 2020 EvUp on the use of various pad sizes, types, and placement for pediatric defibrillation, 1 new pediatric study was identified since 2010 examining the use of different defibrillator pad positions in children with shockable rhythms in cardiac arrest. Our EvUp in 2022 did not find any new pediatric studies on the topics of defibrillator pad size, type, or placement in pediatric cardiac arrest. There are few pediatric-specific studies on the topics of defibrillator pad size, type, or placement in pediatric cardiac arrest. No Antiarrhythmics for children in cardiac arrest with shockable rhythms at any time during CPR or immediately after ROSC 2018 We suggest that amiodarone or lidocaine may be used for the treatment of pediatric shockresistant VF/pVT (weak recommendation, very low–quality evidence). 0 1 The only new evidence since the last SysRev in 2018 is an observational study using the GWTG database that found no significant difference in outcomes when propensitymatched scores were used to compare children who received lidocaine and children who received amiodarone for shockable rhythm during cardiac arrest. A SysRev was also reported in a brief research letter with limited description of methods. No Adenosine use in SVT 2020 This treatment recommendation is unchanged from 2010. 0 0 There have not been any new studies on the use of adenosine in SVT since our last review. For infants and children with SVT with a palpable pulse, adenosine should be considered the preferred medication. Verapamil may be considered an alternative therapy in older children, but it should not be routinely used in infants. Procainamide or amiodarone given by a slow intravenous infusion with careful hemodynamic monitoring may be considered for refractory SVT. Moderate-quality evidence shows no differences in effects of adenosine and calcium channel antagonists for treatment of SVT on reverting to sinus rhythm, and low-quality evidence suggests no appreciable differences in the incidence of hypotension. A study comparing patient experiences and prospectively studied adverse events would provide evidence on which treatment is preferable for management of SVT. No (Continued ) Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e227 Table 16. Continued Topic/PICOST Year last updated Existing treatment recommendation RCTs since last review, n Observational studies since last review, n Key findings Sufficient data to warrant SysRev? Energy doses for pediatric defibrillation 2015 The ILCOR treatment recommendations from 2020 remain unchanged: We suggest the routine use of an initial dose of 2–4 J/kg of monophasic or biphasic defibrillation waveforms for infants or children in VF or pVT cardiac arrest. There is insufficient evidence on which to base a recommendation for second and subsequent defibrillation dosages. 0 1 The 2020 ScopRev identified a single 2019 SysRev that identified no pediatric studies linking the initial or cumulative energy delivered with survival to hospital discharge and no link between long-term survival or survival with good neurological outcome. Meta-analysis could not be performed because the component population groups were extremely heterogeneous. Our EvUp in 2022 identified 1 new pediatric study on this subject. This in-hospital registry study had been noted in the 2020 ScopRev but had not been published until after the initial search and thus was not included in the analysis. Differences remain in the first shock dose recommended by ILCOR member councils, with the ERC and ANZCOR recommending 4 J/kg for the first and all subsequent shocks and the AHA recommending an initial dose of 2–4 J/kg (for ease of teaching, a dose of 2 J/kg is used in algorithms and training materials). For refractory VF, the AHA guidelines recommend increasing the defibrillation dose to 4 J/kg, suggesting that subsequent energy doses should be at least 4 J/kg and noting that higher levels may be considered, not to exceed 10 J/kg. The recently performed SysRev failed to show a significant benefit of one dosing regimen over another but was hampered by small sample sizes and study heterogeneity. The more recent large pediatric in-hospital registry study provided support for a 2–J/kg dose for initial defibrillation but did not provide guidance for subsequent doses. No Single or stacked shocks for pediatric defibrillation (PLS 389) 2020 The ILCOR treatment recommendations from 2020 should remain unchanged: A single-shock strategy followed by immediate CPR (beginning with chest compressions) is recommended for children with out-of-hospital or in-hospital VF or pVT. 0 0 In the 2020 EvUp, there were no new pediatric studies since 2010 on the comparative clinical outcomes from the use of single defibrillation vs >1 shock for the initial or subsequent defibrillation attempt(s) in children with shockable rhythms in cardiac arrest in any setting. They identified a single observational study on transthoracic impedance during defibrillation in children ≥8 y of age (n=5) that suggested that stacked shocks may not improve defibrillation success. Our EvUp in 2022 did not find any new pediatric studies on this subject. As in the previous EvUp, we identified several adult studies, but they were excluded in view of the differences in physiology and pathophysiology of shockable rhythms in pediatric cardiac arrests and may not be extrapolatable to the pediatric population. Despite several recent adult studies comparing single and stacked shocked in very selected settings, there remains very little pediatric-specific evidence in this area. No (Continued ) Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e234 In preterm infants (<34 weeks’ gestation) immediately after birth, we recommend the use of a plastic bag or wrap to maintain normal temperature (strong recommendation, moderate-certainty evidence). Temperature should be carefully monitored and managed to prevent hyperthermia (good practice statement). In preterm infants (<34 weeks’ gestation) immediately after birth, we suggest the use of a head covering to maintain normal temperature (strong recommendation, moderate-certainty evidence). In preterm infants (<34 weeks’ gestation) immediately after birth, we suggest that heated and humidified gases for respiratory support in the delivery room can be used when an audit shows that admission hypothermia is a problem and resources allow (conditional recommendation, very low–certainty evidence). In preterm infants (<34 weeks’ gestation) immediately after birth, there is insufficient published evidence to suggest for or against the use of a radiant warmer in servo-controlled mode compared with manual mode for maintaining normal temperature. In preterm infants (<34 weeks’ gestation), there is insufficient published evidence to suggest for or against the use of skin-to-skin care immediately after birth. Skinto-skin care may be helpful for maintaining normal temperature when few other effective measures are available (good practice statement). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website, and the evidenceto-decision table is provided in Appendix A.225 Key discussion points included the following: • For ambient temperature, some of the evidence was indirect from a study that included late preterm and term infants.250 The safe upper limit of room temperature was not identified, and it may also be affected by ambient humidity. • For plastic bags or wraps, which have been recommended by ILCOR since 2010,263 the evidence of benefit for survival is now of high certainty, and their Table 21. Use of Plastic Cap Compared With No Cap for Newborn Infants Born at <34 Weeks’ Gestation Outcomes (importance) Participants (studies), n Certainty of evidence (GRADE) RR (95% CI) Anticipated absolute effect Risk or mean with standard care RD or MD with plastic cap Survival (critical) 64 (1 RCT)247 Moderate 0.97 (0.84–1.12) 938/1000 28 fewer infants survived per 1000 (150 fewer to 113 more infants) Normothermia (important) 64 (1 RCT)247 Moderate 6.00 (1.96–18.38) 94/1000 469 more normothermic infants per 1000 (90 more to 1629 more); NNTB, 2 infants Mean body temperature– axillary (important) 64 (1 RCT)247 Moderate Not applicable 35.3° C MD, 0.8° C higher (0.41° C higher to 1.19° C higher) Hypothermia or cold stress (important) 64 (1 RCT)247 Moderate 0.48 (0.32–0.73) 906/1000 471 fewer hypothermic or cold-stressed infants per 1000 (616 fewer to 245 fewer); NNTB, 2 infants GRADE indicates Grading of Recommendations Assessment, Development, and Evaluation; MD, mean difference; NNTB, number needed to treat to benefit; RCT, randomized controlled trial; RD, risk difference; and RR, risk ratio. Table 22. Heating and Humidification of Gases for Resuscitation Compared With No Heating and Humidification of Gases for Newborn Infants Born at <34 Weeks’ Gestation Outcomes (importance) Participants (studies), n Certainty of evidence (GRADE) RR (95% CI) Anticipated absolute effect Risk or mean with standard care RD or MD with heated and humidified gases Survival (critical) 476 (2 RCTs)238,239 Very low 1.00 (0.94–1.05) 918/1000 0 fewer/more infants survived per 1000 (55 fewer to 56 more) Normothermia on admission (important) 476 (2 RCTs)238,239 Very low 1.23 (0.93–1.62) 471/1000 108 more infants were normothermic per 1000 (33 fewer to 292 more) Mean axillary body temperature (important) 476 (2 RCTs)238,239 Moderate Not applicable 36.6° C MD 0.15° C higher (0.03° C higher to 0.26° C higher) Moderate hypothermia 476 (2 RCTs)238,239 Low 0.58 (0.36–0.94) 172/1000 72 fewer hypothermic infants per 1000 (68 fewer to 7 fewer); NNTB, 14 infants IVH above grade 2 476 (2 RCTs)238,239 Moderate 0.39 (0.17–0.91) 82/1000 50 fewer infants had IVH per 1000 (68 fewer to 7 fewer); NNTB, 42 infants GRADE indicates Grading of Recommendations Assessment, Development, and Evaluation; IVH, intraventricular hemorrhage; MD, mean difference; NNTB, number needed to treat to benefit; RCT, randomized controlled trial; RD, risk difference; and RR, risk ratio. Note: Gases refers to air and oxygen (reticulated or from cylinders). Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e235 use is considered standard of care in many neonatal services. They were considered feasible to use in lowand high-resource settings, including for outof-hospital births. • For head coverings, the only evidence from an RCT related to use of a plastic cap. Evidence from an observational study222 and indirect evidence from studies of late preterm and term infants suggest that caps made of cloth are also likely effective.261 • For thermal mattresses, safety warnings exist for risk of hyperthermia and skin burns. Nevertheless, the task force concluded that thermal mattresses can be used with care, primarily when other methods to maintain normal temperature are unavailable or insufficient. • Larger studies reporting shortand longer-term outcomes are needed to determine the role of heated and humidified gases for newborn resuscitation. Although their use for assisted ventilation is regarded as routine during subsequent neonatal intensive care, providing them for every birth at <34 weeks’ gestation is likely to be unaffordable in many settings. A conditional recommendation was therefore developed. • A common theme across comparisons was that each study examined the relevant intervention in the context of multiple cointerventions that may have affected the reported effect size. Indeed, it is likely that a bundle of interventions operating through different mechanisms is needed for most preterm infants. However, the review did not identify sufficient evidence for any specific bundle. The design of such bundles should be based on the certainty of evidence for each intervention in addition to the availability of resources and local environmental considerations. • The risk of harm from hyperthermia is likely to be higher when multiple interventions are used concurrently. Early measurement of temperature may detect when additional measures are needed for individual infants, and regular audit is needed to ensure that strategies achieve maintenance of normal temperature for most infants. Task Force Knowledge Gaps • Whether specific bundles of interventions are beneficial to maintain normal temperature compared with other specific bundles • How ambient temperature and humidity affect the effectiveness of any means to maintain normal temperature • Cost-effectiveness of any of the interventions studied • The optimal set temperatures for the operating theater and other delivery room settings • The role of thermal mattresses for births in prehospital settings when other devices and methods for maintaining normal temperature are unavailable • The risks and benefits of using head coverings composed of different materials • Whether the use of heated and humidified gases during resuscitation reduces lung injury or severe intraventricular hemorrhage • The role of servo control in maintaining normal temperature in preterm infants requiring prolonged resuscitation • Whether servo-controlled devices could be adapted for use during deferred cord clamping • Whether the efficacy of a radiant warmer used in servo-controlled mode depends on the position of the temperature sensor probe • What other interventions to maintain normal temperature are effective (and can be safely adapted) for use during skin-to-skin care Heart Rate Monitoring: Diagnostic Characteristics (SysRev) Rationale for Review Heart rate is considered one of the most important indicators of an infant’s condition at birth. Limitations of assessing heart rate by palpation of pulses or by pulse Table 23. Servo Control of Radiant Warmer Compared With Manual Control for Infants Born at <34 Weeks’ Gestation Outcomes (importance) Participants (studies), n Certainty of evidence (GRADE) RR (95% CI) Anticipated absolute effect Risk or mean with manual control RD or MD with servo control Survival (critical) 450 (1 RCT)258 Moderate 1.05 (0.99–1.11) 884/1000 44 more infants survived per 1000 (9 fewer to 97 more) Normothermia on admission (important) 450 (1 RCT)258 Moderate 0.94 (0.75–1.17) 422/1000 25 fewer normothermic infants per 1000 (106 fewer to 72 more) Mean body temperature (important) 450 (1 RCT)258 Moderate Not applicable 36.5° C MD 0.2° C lower (0.33° C lower to 0.07° C lower) Hypothermia or cold stress 450 (1 RCT)258 Moderate 1.20 (1.01–1.42) 498/1000 100 more hypothermic or cold-stressed infants per 1000 (5 more to 209 more); NNTH, 2 infants GRADE indicates Grading of Recommendations Assessment, Development, and Evaluation; MD, mean difference; NNTH, number needed to treat to harm; RCT, randomized controlled trial; RD, risk difference; and RR, risk ratio. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e236 oximetry were identified in a 2015 ILCOR SysRev, which found that electrocardiography was faster and more accurate.221 A 2020 EvUp found studies using newer devices and methods.264 A 2022 ILCOR SysRev found little evidence to suggest improvement in critical and important clinical outcomes with the use of electrocardiography compared with pulse oximetry.58 However, heart rate influences critical decisions about resuscitation at birth, so a SysRev was conducted to assess the diagnostic characteristics of various devices and methods for measuring heart rate in the first minutes after birth (PROSPERO registration CRD 42021283364). See the ILCOR website for the full online CoSTR.265 PICOST • Population: Newborn infants in the delivery room • Intervention: Use of auscultation, palpation, pulse oximetry, Doppler device, digital stethoscope, photoplethysmography, video plethysmography, dry electrode technology, or any other newer modalities • Comparators: ECG or between-method comparisons • Outcomes: - Important: Time to first heart rate assessment from the device placement, time to first heart rate assessment from birth, and accuracy of heart rate assessment For the purposes of this SysRev, electrocardiographic heart rate was considered the gold standard. Accuracy of heart rate assessment by other methods was examined with the following: • Pooled Bland-Altman analysis266–270 to estimate bias, a measure of accuracy, and the limits of agreement, a measure of precision. For the purposes of the review, agreement within ±10 bpm was considered acceptable. • Pooled sensitivity and specificity analysis to identify electrocardiographic heart rate <100 and <60 bpm Further details about methods are included in the full online CoSTR.265 • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, and cohort studies) were eligible for inclusion. • Time frame: All years and all languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols) were excluded. The literature search was updated to August 5, 2022. Consensus on Science Comparison 1: Pulse Oximeter Versus Electrocardiography The SysRev identified 3 RCTs271–273 including 187 infants and 11 cohort studies274–284 including 490 infants. Data relating to the key outcomes for the comparison of pulse oximetry and electrocardiography are summarized in Table 24. These results indicate that pulse oximetry is slower and more imprecise than electrocardiography is for heart rate assessment at birth. Additional outcomes are included in the full online CoSTR.265 Comparison 2: Auscultation Compared With Electrocardiography The SysRev identified 5 observational studies including 171 infants.275,285–288 Data relating to the key outcomes for the comparison of auscultation and electrocardiography are summarized in Table 25. These results indicate that auscultation may be faster and accurate but is imprecise compared with electrocardiography for heart rate assessment at birth. Additional outcomes are included in the full online CoSTR.265 Comparison 3: Palpation Versus Electrocardiography The SysRev identified 2 observational studies including 86 infants.285,286 Data relating to the key outcomes for the comparison of palpation with electrocardiography are summarized in Table 26. These results indicate that Table 24. Pulse Oximetry Compared With Electrocardiography for Measuring HR at Birth: Diagnostic Characteristics Outcomes Participants (studies), n Certainty of evidence (GRADE) Pooled median difference or bias MD (95% CI) or LoA (95% CI) Time to first HR from device placement 136 (2 RCTs)272,273 Very low 12 s slower 38 s slower to 13 s faster 323 (6 observational studies)274,276,279,280,282,284 Low 57 s slower 101 s slower to 13 s slower Time to first HR from birth 87 (2 RCTs)271,273 Low 6 s slower 23 s slower to 10 s faster 334 (6 observational studies)274,275,277,283–285 Low 52 s slower 94 s slower to 9 s slower Accuracy of HR assessment 216 infants (1 RCT, 4 observational studies 28 211 observations)271,277,278,281,284 Moderate HRPO−HRECG, –1.2 bpm LoA, −17.9 to 15.5 bpm (95% CI, −32.8 to 30.4) Accuracy of HR assessment (sensitivity and specificity of pulse oximetry for HR <100 bpm) 124 (3 studies)271,279,281 8342 observations Very low Sensitivity, 0.83 (95% CI, 0.76 to 0.88) Specificity, 0.97 (95% CI, 0.93 to 0.99) GRADE indicates Grading of Recommendations Assessment, Development, and Evaluation; HR, heart rate; HRECG, heart rate measured with electrocardiography; HRPO, heart rate measured with pulse oximetry; LoA, limits of agreement; and RCT, randomized controlled trial. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e237 palpation is inaccurate and imprecise compared with electrocardiography for heart rate assessment at birth. Additional outcomes are included in the full online CoSTR.265 Some studies were also found for each of the following comparisons, and the evidence is included in the full online CoSTR.265 None of the evidence was considered sufficient to develop treatment recommendations: • Comparison 4: Palpation compared with auscultation • Comparison 5: Digital stethoscope compared with electrocardiography • Comparison 6: Doppler ultrasound compared with electrocardiography • Comparison 7: Dry electrodes incorporated into a belt compared with (conventional 3-lead) electrocardiography Prior Treatment Recommendations 2015: In babies requiring resuscitation, we suggest that electrocardiography can be used to provide a rapid and accurate estimation of heart rate (weak recommendation, very low–quality evidence). 2022: When resources permit, we suggest that the use of electrocardiography for heart rate assessment of a newborn infant requiring resuscitation in the delivery room is reasonable (weak recommendation, low-certainty evidence). When electrocardiography is not available, auscultation with pulse oximetry is a reasonable alternative for heart rate assessment, but the limitations of these modalities should be kept in mind (weak recommendation, low-certainty evidence). There is insufficient evidence to make a treatment recommendation for the use of digital stethoscope, audible or visible Doppler ultrasound, dry electrode technology, reflectance-mode green light photoplethysmography, or transcutaneous electromyography of the diaphragm for heart rate assessment of a newborn in the delivery room. Auscultation with or without pulse oximetry should be used to confirm the heart rate when electrocardiography is unavailable or is not functioning or when pulseless electrical activity is suspected (good practice statement). 2023 Treatment Recommendations When accurate heart rate estimation is needed for a newborn infant immediately after birth and resources permit, we suggest that the use of electrocardiography is reasonable (conditional recommendation, low-certainty evidence). Pulse oximetry and auscultation may be reasonable alternatives to electrocardiography for heart rate assessment, but the limitations of these modalities should be kept in mind (conditional recommendation, low-certainty evidence). There is insufficient evidence to make a treatment recommendation for the use of any other device for heart rate assessment of a newborn infant immediately after birth. Auscultation with or without pulse oximetry should be used to confirm the heart rate when electrocardiography is unavailable or is not functioning or when pulseless electrical activity is suspected (good practice statement). Justification and Evidence-to-Decision Framework Highlights The complete evidence-to-decision framework can be found on the ILCOR website,265 and the evidence-todecision table is provided in Appendix A. Key points of discussion include the following: • The treatment recommendations reflect the results of both this review and the 2022 ILCOR SysRev of clinical outcomes of different methods of heart rate assessment.58 • The available data suggest that electrocardiography provides a more rapid and accurate assessment of heart rate in the delivery room compared with pulse Table 25. Auscultation Compared With Electrocardiography for Measuring HR at Birth: Diagnostic Characteristics Outcomes Participants (studies), n Certainty of evidence (GRADE) Pooled median difference or bias 95% CI or LoA (95% CI) Time for first HR from device placement 105 (3 observational studies)275,287,288 Moderate 4 s faster 10 s faster to 2 s slower Time for first HR from birth 70 (2 observational studies)275,288 Low 24 s faster 45 s faster to 2 s faster Accuracy of HR assessment 71 (2 observational studies)285,287 Low HRaus− HRECG, −9.9 bpm LoA, −32 to 12 bpm (95% CI, −217 to 198) GRADE indicates Grading of Recommendations Assessment, Development, and Evaluation; HR, heart rate; HRaus, heart rate measured with auscultation; HRECG, heart rate measured with electrocardiography; and LoA, limits of agreement. Table 26. Palpation Compared With Electrocardiography for Measuring HR at Birth: Diagnostic Characteristics Outcomes Participants (studies), n Certainty of evidence (GRADE) Mean±SD MD±SEM Accuracy of HR assessment 21 (1 observational study)285 Very low HRpalp 147±19 bpm vs HRECG 168±22 bpm –21±21 bpm GRADE indicates Grading of Recommendations Assessment, Development, and Evaluation; HR, heart rate; HRECG, heart rate measured with electrocardiography; HRpalp, heart rate measured with palpation; and MD, mean difference. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e238 oximetry and more accurate assessment than palpation or auscultation, but the certainty of evidence ranges from moderate to very low. • Most studies did not include the infants in whom rapid, accurate assessment of heart rate may be most important, for example, infants who were bradycardic, were requiring resuscitation, or were extremely premature. The companion SysRev that assessed clinical outcomes58 found that it is unclear whether rapidity, accuracy, and precision of heart rate estimation at birth result in clinically relevant differences in resuscitation interventions, resuscitation team performance, or clinical outcomes for newborn infants. • Auscultation, pulse oximetry, or both have been routinely used for heart rate assessment in newborns at birth. When resources are limited, the addition of another device may be impractical or unaffordable. Task Force Knowledge Gaps • More data are needed on the characteristics of measurement of heart rate in the delivery room with devices such as digital stethoscope, Doppler ultrasound (audible or visible displays), reflectancemode green light photoplethysmography, or devices detecting electrocardiography using dry electrodes. Such studies should include evaluation of time to first heart rate assessment from birth and from device placement. • Cost-effectiveness of different modalities for heart rate assessment in the delivery room • Impact of different heart rate assessment methods on resuscitation team performance, resuscitation interventions, and neonatal clinical outcomes • Evidence as to whether different devices are better suited to different subgroups of infants (eg, by gestation or by anticipated need for advanced resuscitation) Exhaled CO2 Detection to Guide Noninvasive Ventilation (SysRev) Rationale for Review ILCOR has previously evaluated the use of CO2 monitoring to confirm correct placement of tracheal tubes (colorimetric devices) and during invasive ventilation to improve CO2 levels on admission to a neonatal unit, but these reviews did not include a GRADE evaluation.263 CO2 monitoring devices have also been systematically reviewed (as part of a review of several feedback devices) in newborn infants for detecting ROSC.221 More recent studies have examined the use of CO2 detection to guide noninvasive ventilation at birth, the focus of the current review. A SysRev was initiated from a priority list from the ILCOR NLS Task Force (PROSPERO registration CRD42022344849). See the ILCOR website for the full online CoSTR.289 PICOST • Population: Newborn infants receiving intermittent positive-pressure ventilation (IPPV) by any noninvasive interface at birth • Intervention: Use of exhaled CO2 monitor in addition to clinical assessment, pulse oximetry, or electrocardiography • Comparators: Clinical assessment, pulse oximetry, or electrocardiography only • Outcomes: - Critical: Survival - Important: Tracheal intubation in the delivery room, other resuscitation outcomes at birth, other major morbidities, and unexpected admission to special or ICU in infants born at ≥34 weeks’ gestation. • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, and cohort studies) were eligible for inclusion. Case series, case reports, animal studies, and unpublished studies (conference abstracts, trial protocols) were excluded. • Time frame: All years and all languages were included as long as there was an English abstract. The literature search was updated to August 1, 2022. Consensus on Science The SysRev identified 23 studies that addressed the use of CO2 monitoring during noninvasive IPPV. In only 8 of these (including 419 infants) were CO2 detection devices or monitor displays visible to those performing the resuscitation.290–297 The devices for positive-pressure ventilation varied (T-piece device, self-inflating bag, flow-inflating bag), but the interface in all studies was a face mask. None of the studies were designed to address the PICOST question, and differences in study design precluded any meta-analysis. The following sections summarize the findings of a narrative review of these studies; further description is included in the full online CoSTR.289 Exhaled CO2 Monitoring and Airway Obstruction Two observational studies including 59 preterm infants described continuous use of a colorimetric CO2 detection device during noninvasive IPPV and recorded that health care professionals responded to its display with corrective actions.290,292 Exhaled CO2 to Assess Lung Aeration One RCT of sustained inflation including 162 infants297 and 2 observational studies together including 95 infants291,294 suggested that monitoring of exhaled CO2 is feasible (including while providing face mask IPPV during delayed umbilical cord clamping291) and that a rise in exhaled CO2 correlates with improvements in lung aeration. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e239 Exhaled CO2 as a Predictor of Increase in Heart Rate in Initially Bradycardic Infants One observational study including 41 bradycardic preterm infants concluded that a change in a colorimetric CO2 detector device precedes a clinically significant increase in heart rate.290 A second study including 7 infants found that an exhaled CO2 level >15 mm Hg preceded a clinically significant increase in heart rate.296 Exhaled CO2 and Pco2 at NICU Admission One RCT including 37 preterm infants born at <34 weeks’ gestation compared a visible with a masked CO2 monitor and found no difference in the proportion of infants with Pco2 in the target range on NICU admission.295 One RCT including 59 infants born at <32 weeks’ gestation compared quantitative and qualitative CO2 monitoring and found no differences in Pco2 in the target range on NICU admission.293 Prior Treatment Recommendations None 2023 Treatment Recommendation There is insufficient evidence to suggest for or against the use of exhaled CO2 to guide noninvasive IPPV with noninvasive interfaces such as face masks, supraglottic airways, and nasal cannulas in infants immediately after birth. Justification and Evidence-to-Decision Framework Highlights The evidence-to-decision table for this topic can be found in Appendix A, and the full text of the evidenceto-decision highlights is on the ILCOR website.289 Key discussion points included the following: • There were no studies in infants receiving noninvasive IPPV in the delivery room that compared use of CO2 monitoring (using quantitative or qualitative devices) with no device or a masked device that demonstrated improvement in any clinical outcome. The combined studies did suggest that both types of devices are feasible to use, that they may assist with detection of airway obstruction and other causes of inadequate lung aeration and ventilation, and that increases in exhaled CO2 precede improvements in heart rate in bradycardic infants. • Concerns about the use of quantitative and qualitative exhaled CO2 monitoring devices to improve noninvasive IPPV include the potential for misinterpretation; it may not be possible to differentiate inadequate tidal ventilation from very low pulmonary blood flow as a cause for low exhaled CO2, and dead space ventilation (physiological or equipment related) could lead to overestimation of exhaled CO2. • The reliability of colorimetric CO2 devices may be affected by contamination with gastric contents or medications.290,298 Task Force Knowledge Gaps • The efficacy and effectiveness of different devices for CO2 monitoring to guide noninvasive IPPV via face mask or supraglottic airway device in newborns immediately after birth for infants of various birthweights in various clinical settings • The optimal range for exhaled CO2 in each minute after birth • The effect of gastric reflux, other secretions, blood, meconium, or medications on the reliability of colorimetric CO2 detectors • The potential for CO2 monitoring to distract or bias health care professionals • Cost-effectiveness of CO2 monitoring Heart Rate to Initiate Chest Compressions (ScopRev) Rationale for Review The recommended heart rate threshold for initiating chest compressions during resuscitation at birth has been <60 bpm since 1999; at the same time, the optimal heart rate threshold for initiating chest compressions has been identified as a gap in knowledge.299 A ScopRev was initiated from a priority list from the ILCOR NLS Task Force.300 See the ILCOR website for the full online CoSTR.301 PICOST • Population: Newborn infants immediately after birth who are being resuscitated with ventilation and who have a slow heart rate • Intervention: Starting cardiac compressions at other heart rate thresholds • Comparators: Starting cardiac compressions when the heart rate is <60 bpm • Outcomes: - Critical: survival, neurological outcomes - Important: Any other reported shortor long-term outcomes, including time to ROSC • Study designs: RCTs, nonrandomized studies (nonRCTs, interrupted time series, controlled beforeand-after studies, cohort studies), and case series were eligible for inclusion. Manikin, computer model, and animal studies were eligible for inclusion. Conference abstracts and unpublished studies (eg, trial protocols) were excluded. • Time frame: All years and all languages were included as long as there was an English abstract. The literature search was updated to November 22, 2021. Summary of Evidence No studies were found that examined different heart rate thresholds for initiating chest compressions in newborn infants immediately after birth. There is also very little evidence from animal studies.302 Further description is included in the full online CoSTR.301 Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e240 Task Force Insights The heart rate threshold of <60 bpm was originally selected on the basis of expert opinion and a desire to simplify the resuscitation algorithm. The ScopRev provided no data sufficient to alter the existing recommendation, but the optimal threshold and whether it differs for different subgroups of infants remain unknown. Treatment Recommendations ILCOR has not developed an evidence-based treatment recommendation for heart rate threshold to initiate chest compressions previously. However, ILCOR guidance since 1999 has been to initiate chest compressions if the heart rate is <60 bpm despite adequate assisted ventilation for 60 seconds.299 Insufficient evidence was found in the ScopRev to support a new SysRev or a different recommendation. Supplemental Oxygen During Chest Compressions (ScopRev) Rationale for Review A 2015 ILCOR SysRev examined evidence for 100% O2 as the ventilation gas during chest compressions compared with lower concentrations of O2 and concluded that there were no human data to inform this question.221 Surveillance of resuscitation literature suggested that there may be more recent studies, including indirect evidence from animal models. A ScopRev was initiated from a priority list from the ILCOR NLS Task Force.300 See the ILCOR website for the full online CoSTR.303 PICOST • Population: Newborn infants immediately after birth who received chest compressions • Intervention: Any lower concentrations of O2 • Comparators: 100% O2 as the ventilation gas • Outcomes: - Critical: Survival, neurological outcomes - Important: Any other reported shortor long-term outcomes, including time to ROSC • Study designs: RCTs, nonrandomized studies (nonRCTs, interrupted time series, controlled beforeand-after studies, cohort studies), and case series were eligible for inclusion. Manikin, computer model and animal studies were also eligible for inclusion. Conference abstracts and unpublished studies (eg, trial protocols) were excluded. • Time frame: All years and all languages were included as long as there was an English abstract. The literature search was updated to November 22, 2021. Summary of Evidence No human studies that compared any other oxygen concentration with 100% O2 during chest compressions were identified. Six animal studies comparing 21% with 100% inspired O2 concentrations during chest compressions after asphyxial cardiac arrest were identified. Overall, they found no differences in time to ROSC, mortality, inflammation, or oxidative stress.304–309 Further description is included in the full online CoSTR.303 Task Force Insights The available evidence from animal studies suggests that resuscitation using 21% O2 during chest compressions is feasible and results in similar short-term outcomes. However, the animal studies examined only asphyxia-induced asystole of brief duration in animals lacking other underlying pathological conditions, and there are no human infant data. The available evidence was insufficient to warrant a new SysRev or to suggest the need to alter the current treatment recommendation. Treatment Recommendations The 2015 good practice statement remains unchanged: Despite animal evidence showing no advantage to the use of 100% oxygen, by the time resuscitation of a newborn infant has reached the stage of chest compressions, the steps of trying to achieve ROSC using effective ventilation with low-concentration oxygen should have been attempted. Thus, it would seem prudent to try increasing the supplementary oxygen concentration (good practice statement).221 Neonatal Chest Compression Technique (Other Techniques Versus 2-Thumb Technique; ScopRev) Rationale for Review A 2015 ILCOR SysRev examined evidence for a 2-thumb technique compared with a 2-finger technique for neonatal chest compressions and recommended a 2-thumb technique on the basis of very low–certainty evidence from nonrandomized studies and a single manikin study.221 Surveillance of resuscitation literature identified more recent studies examining other techniques. A ScopRev was initiated from a priority list from the ILCOR NLS Task Force and has been published.300 See the ILCOR website for the full online CoSTR.310 PICOST • Population: Newborn infants immediately after birth who received chest compressions • Intervention: Use of any other technique (2-finger or other technique) for chest compressions • Comparator: 2-thumb technique for chest compressions • Outcomes: - Critical: Survival and neurological outcomes - Important: Any other reported shortor long-term outcomes, including time to ROSC • Study designs: RCTs, nonrandomized studies (non-RCTs, interrupted time series, controlled Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e241 before-and-after studies, cohort studies), and case series were eligible for inclusion. Manikin, computer model, and animal studies were also eligible for inclusion. Conference abstracts and unpublished studies (eg, trial protocols) were excluded. • Time frame: All years and all languages were included as long as there was an English abstract. The literature search was updated to November 22, 2021. Summary of Evidence The current ScopRev identified 29 randomized crossover manikin studies, 1 observational study, and 1 randomized study comparing various finger/hand positions.311–340 The available data confirmed that the 2-thumb technique resulted in greater chest compression depth, lower fatigue, and higher proportion of correct hand placement compared with the 2-finger technique. No alternative finger or hand position techniques resulted in overall better performance measures compared with the 2-thumb technique. Further description is included in the full online CoSTR.310 Task Force Insights The information from the studies identified was considered insufficient to warrant a SysRev or to alter existing recommendations. Treatment Recommendations The 2015 treatment recommendation remains unchanged. We suggest that chest compressions in newborn infants immediately after birth should be delivered by the 2-thumb, hands-encircling-the-chest method as the preferred option (weak recommendation, very low–quality evidence). Compression-to-Ventilation Ratio for Neonatal CPR (ScopRev) Rationale for Review The 2015 CoSTR and a subsequent EvUp suggested continuing to use a 3:1 compression-to-ventilation ratio.221,264 There was no evidence from human infants for this ratio, and it was based on animal and manikin studies. However, the EvUp identified sufficient new animal and manikin studies and 1 small clinical trial to justify inclusion in the multifaceted ScopRev of questions related to chest compressions. A ScopRev was initiated from a priority list from the ILCOR NLS Task Force.300 See the ILCOR website for the full online CoSTR.341 PICOST • Population: Newborn infants immediately after birth who received chest compressions • Intervention: Any other compression-to-ventilation ratio (5:1, 9:3, 15:2, asynchronous) • Comparators: 3:1 compression-to-ventilation ratio • Outcomes: - Critical: Survival and neurological outcomes - Important: Any other reported shortor long-term outcomes, including time to ROSC hemodynamic parameters, tissue oxygenation, lung or brain inflammatory markers, and compressor fatigue • Study designs: RCTs, nonrandomized studies (nonRCTs, interrupted time series, controlled beforeand-after studies, cohort studies), and case series were eligible for inclusion. Manikin, computer model, and animal studies were also eligible for inclusion. Conference abstracts and unpublished studies (eg, trial protocols) were excluded. • Time frame: All years and all languages were included as long as there was an English abstract. The literature search was updated to November 22, 2021. Summary of Evidence The ScopRev identified 23 studies examining different compression-to-ventilation ratios, continuous chest compressions with asynchronous ventilation, or chest compressions with sustained inflation.304,305,307,342–361 These studies are summarized in Table 27, and further details are available in the full online CoSTR.341 Task Force Insights The information from the studies identified was considered insufficient to alter the existing recommendation. The task force noted that a larger trial of chest compressions with sustained inflation is underway (ClinicalTrials. gov identifier: NCT02858583). Treatment Recommendations The 2015 treatment recommendation remains unchanged. We suggest continued use of a 3:1 compression-toventilation ratio for CPR in newborn infants immediately after birth (weak recommendation, very low–certainty evidence). Use of Feedback CPR Devices for Neonatal Cardiac Arrest (ScopRev) Rationale for Review The use of feedback devices such as end-tidal carbon dioxide (ETCO2) monitors, pulse oximeters, or automated compression feedback devices was considered in an ILCOR 2015 SysRev.221 Surveillance of resuscitation literature suggested that there may be more recent studies, including indirect evidence from animal models. A ScopRev was initiated from a priority list from the ILCOR NLS Task Force.300 See the ILCOR website for the full online CoSTR.362 Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e242 PICOST • Population: Newborn infants immediately after birth who received chest compressions • Intervention: Use of any feedback devices such as ETCO2 monitors, pulse oximeters, or automated compression feedback devices • Comparators: Clinical assessments of compression efficacy • Outcomes: - Critical: Survival and neurological outcomes - Important: Hands-off time, time to ROSC, and perfusion • Study designs: RCTs, nonrandomized studies (nonRCTs, interrupted time series, controlled beforeand-after studies, cohort studies), and case series were eligible for inclusion. Manikin, computer model, and animal studies were also eligible for inclusion. Conference abstracts and unpublished studies (eg, trial protocols) were excluded. • Time frame: All years and all languages were included as long as there was an English abstract. The literature search was updated to November 22, 2021. Summary of Evidence The ScopRev identified 18 studies that addressed chest compression feedback devices: 12 manikin studies,363–373 4 animal studies,374–377 and 2 human infant studies.378,379 Twelve of the studies used randomized allocation to study arms. Most of the manikin studies assessed musical, auditory, tactile, or other signals to improve the cadence of chest compressions, but 1 manikin study tested a decision support tool and other devices that detected chest compression depth and rate. All reported improvements in chest compression rate, consistency, depth, or other measures of quality in the simulation setting, but none reported translation of the device or improvement in skills as a result of using the device into improvements in performance or infant outcomes in clinical settings. All the animal studies tested the role of ETCO2 in improving resuscitation outcomes or in predicting ROSC. No differences were found in ROSC or survival from using ETCO2 to guide chest compressions.374–377 One of the 2 retrospective human infant studies assessed a practice change to increase depth of chest compressions,378 and 1 study evaluated ETCO2 as a predictor of ROSC.379 Details are available in the full online CoSTRs.362 Task Force Insights The body of available evidence does not justify an ILCOR SysRev at this time because no studies assessed whether feedback devices result in improvements in resuscitation practice or outcomes in human infants. Further research is justified, including assessing whether improvements measured in simulation settings result in improvement in clinical performance or outcomes and to assess the role of capnography and other types of clinical measurements in improving outcomes in infants who receive chest compressions. Treatment Recommendations The 2015 treatment recommendation remains unchanged. In newborn infants with asystole or bradycardia, we suggest against the routine reliance on any single feedback device such as ETCO2 monitors or pulse oximeters for detection of ROSC until more evidence becomes available (weak recommendation, very low–certainty evidence). EDUCATION, IMPLEMENTATION, AND TEAMS Family Presence in Adult Resuscitation (SysRev) Rationale for Review Low survival rates suggest that cardiac arrest is a pivotal event during which family members may wish to be present during resuscitative efforts.380 Family presence has been advocated to improve coping and grieving outcomes for families, to reduce litigation, and to improve resuscitation Table 27. Chest Compression–to–Ventilation Ratio for Neonatal Resuscitation Compressionto-ventilation ratio 2 RCTs, manikin studies346,359 3:1 vs 5:1 vs 15:2 ratios; 3:1 was associated with more consistent CC depth and preferred by rescuers.346 No differences in compressor fatigue among 3:1, 5:1, 10:2, 15:2 ratios, but 3:1 rated more difficult359 5 RCTs, piglet studies304,305,307,352,357 No differences in time to ROSC, survival, biomarkers of brain or organ injury between various ratios, including 3:1, 9:3, 15:2, 2:1, and 4:1 Continuous CC with asynchronous ventilation 5 RCTs, manikin studies343–345,347,358 Variable results but some studies found greater fatigue and lower CC depth with continuous CC with asynchronous ventilation vs 3:1 compression-to-ventilation ratio 6 RCTs, piglets (5) or lambs (1)342,349,350,353,355,361 For time to ROSC and for survival, 1 RCT found improvements with continuous CC with asynchronous ventilation vs 3:1 compression-to-ventilation ratio. One RCT found improved physiological measures with CC with asynchronous ventilation vs 3:1 compression-to-ventilation ratio. CC with sustained inflation 4 RCTs, piglets (3) or lambs (1)348,351,360 Faster time to ROSC but similar survival with CC combined with repeated 20-s sustained inflations vs 3:1 compression-to-ventilation ratio 1 RCT, human infants354 Faster time to ROSC with CC combined with repeated 20-s sustained inflations vs 3:1 compression-to-ventilation ratio CC indicates chest compressions; RCT, randomized controlled trial; and ROSC, return of spontaneous circulation. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e243 team behaviors.380–382 Conversely, concerns have been raised about the distress that family presence during resuscitation may cause families or health care professionals, as well as its impact on team performance.380,383 In 2021, an ILCOR SysRev of family presence during neonatal and pediatric resuscitation was conducted.384 The current SysRev was undertaken on behalf of the Education, Implementation, and Teams (EIT), BLS, and ALS Task Forces to address this question in the adult population (PROSPERO registration CRD4202124238400).385 The full online CoSTR can be found on the ILCOR website.386 PICOST • Population: Adults requiring resuscitation for cardiac arrest in any setting • Interventidcxzon: Family presence during resuscitation • Comparators: Family not present during resuscitation • Outcomes: - Patient outcomes (short and long term): ROSC, survival (to hospital admission, hospital discharge/30 days, 3 months, 6 months, 1 year), survival with good neurological outcomes (at same time points), and depression or anxiety - Family (or significant other) outcomes (short and long term): Posttraumatic stress disorder, coping, perception of the resuscitation, depression or anxiety among family members, and complicated grief syndrome - Health care professional outcomes: Perception of the resuscitation, performance, perceived futility in some circumstances, and psychological stress, including projection to the health care professional’s own family • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were included, and unpublished studies (eg, conference abstracts, trial protocols) were excluded. • Time frame: All years and all languages were included as long as there was an English abstract. The literature search was updated to May 10, 2022. Consensus on Science The 31 studies387–417 included were highly heterogeneous, comprising a range of study designs, with just over half of all the studies having a qualitative study design and only 2 being RCTs (Table 28).387,388 Evidence was very low certainty because of potential confounding and heterogeneity or a lack of information on patient, family, health care professional, and cardiac arrest setting characteristics. Evidence was also downgraded for inconsistency in the reporting of results, indirectness in terms of population, study design, and outcomes of interest and imprecision. Overall, there was no evidence of harm for patients or families from family presence across the studies. However, there was variability in practices and outcomes of family presence during resuscitation; therefore, no metaanalysis was possible. 1. Patient outcomes were reported in 12 studies.388–392,399,404,406,407,411,414,416 Four studies compared family presence with no family presence.388–390,404 Only 1 study found higher rates of ROSC and survival to discharge when no family members were present during resuscitation.389 2. Family outcomes were reported in 15 studies387,388,391–395,403,405–408,411,414,416 investigating depression, anxiety, posttraumatic stress disorder, and experience of witnessing the resuscitation of a family member. Whereas 3 studies reported increased rates of depression391 or posttraumatic stress disorder,393,403 little evidence was found that witnessing a family member’s resuscitation caused one of these mental health conditions. 3. Both positive and negative outcomes were reported when witnessing a family member’s resuscitation. Many family members would witness resuscitation again394,395 because doing so enabled them to better manage their grief.394 Reported negative outcomes included managing emotional responses,407 interfering with resuscitation,407 the dehumanizing nature of resuscitation,405 and the long,395 brutal, dehumanizing, and excessive nature of the resuscitation process.405 4. Health care professional outcomes were measured in 20 studies.387,388,394–402,404,409–415,417 Varying experience with family witnessing resuscitation was Table 28. Family Presence During Adult Resuscitation, Study Characteristics Study designs Investigated environment 31 studies included387–417 2 randomized controlled trials387,388 16 observational studies387–404 12 qualitative studies405–413,415–417 1 mixed-methods study414 24 studies examined in-hospital resuscitation387,389,390,392–402,404,406,407,409,411–416 11 studies in the emergency department387,393–396,402,409,411–413,417 5 studies in the ICU389,398,409,411,416 5 studies in critical care areas397,406,412,413,415 6 studies in all hospital areas390,399,404,409,411,414 3 studies did not report the specific in-hospital context392,400,401 8 studies reported >1 in-hospital location397,404,409,411–414,417 5 studies reported out-of-hospital resuscitation388,391,403,405,410 1 study reported both in-hospital and out-of-hospital resuscitation417 1 study did not clearly report the context408 ICU indicates intensive care unit. Supplemental Table EIT-S1 summarizes the outcomes on patients, family, and health care professionals when family members are present during resuscitation of adult patients after cardiac arrest. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e250 Table 34. EIT Topics Reviewed by EvUps Topic/PICO Year last updated Existing treatment recommendation RCTs since last review, n Observational studies since last review, n Key findings Sufficient data to warrant SysRev? Patient outcomes from team member(s) attending a CPR course (EIT 6106) 2021 We recommend the provision of accredited adult ACLS/ALS training for health care providers who provide ALS care for adults (strong recommendation, very low–certainty evidence). We recommend the provision of accredited NRT courses for health care professionals who provide ALS care for newborns and babies (strong recommendation, very low–certainty evidence). We recommend the provision of Helping Babies Breathe support training for health care providers who provide ALS care for newborns and babies (strong recommendation, very low–certainty evidence). 0 1 One new article was identified relevant to this PICO. The results of these studies support and strengthen the current ILCOR CoSTR recommendation. Given that this is an observational study and no new RCT is available, the identified study would not increase the existing very low certainty of evidence and change the current recommendation. No. This EvUp does not meet the criteria to trigger a new SysRev. CACs (EIT 6301) 2021 We suggest that adult patients with nontraumatic OHCA be cared for in CACs rather than in non-CACs (weak recommendation, very low–certainty evidence). We cannot make a recommendation for or against regional triage by primary EMS transport of patients with OHCA to a CAC by primary EMS transport (bypass protocols) or secondary interfacility transfer to a CAC. The current evidence is inconclusive and confidence in the effect estimates is currently too low to support an EIT and ALS Task Force recommendation. For patients with IHCA, we found no evidence to support an EIT and ALS Task Force recommendation. For the subgroup of patients with shockable or nonshockable initial cardiac rhythm, the current evidence is inconclusive, and the confidence in the effect estimates is currently too low to support an EIT and ALS Task Force recommendation. 0 RCTs 4 SysRevs 4 The SysRevs reported improved outcomes for patients with OHCA who were transported to a CAC. One observational study reported improved survival and neurological outcome for patients who were transferred to a CAC; another found that patients transported to CAC in mixed urban/rural area may have improved survivwal compared with those in a metropolitan area. Two studies comparing highand lowvolume hospitals reported conflicting results, with one reporting better outcomes from high-volume hospitals and one finding no difference in outcomes. Yes. The new evidence will not change the 2020 treatment recommendation. EIT and ALS Task Forces should consider updating the SysRev after the publication of an RCT in 2023 (ARREST; ClinicalTrials.gov identifier, NCT03872960). Technology to summon providers (EIT 6302) 2020 We recommend that citizen/individuals who are in close proximity to a suspected OHCA event and willing to be engaged/notified by a smartphone app with an MPS or TM alert system should be notified (strong recommendation, very low–certainty evidence). 3 SysRevs but 0 RCTs 6 The 3 SysRevs favored first-responder systems; the RCT reported about alarming systems of laypeople by dispatchers. The summary of these studies supports the current ILCOR CoSTR recommendation. Given that no RCT data are available, the identified studies would not change the existing recommendation on the basis of very low certainty of evidence. No. This EvUp does not meet the criteria to trigger a new SysRev. However, the focus on alarming laypeople as first responders might trigger a separate PICOST reviewing the evidence of such systems. Prehospital TOR rules (EIT 6303) 2021 We conditionally recommend the use of TOR rules to assist clinicians in deciding whether to discontinue resuscitation efforts out of hospital or to transport to hospital with ongoing CPR (conditional recommendation, very low–certainty evidence). 0 2 One study applied a medical TOR rule and a surgical TOR rule for pediatric patients (pTOR) and correctly found 322/323 patients as not eligible for the medical pTOR. The traumatic pTOR rule misclassified 4/54 patients with ROSC. This pTOR rule was unable to correctly classify all patients as not eligible for TOR. Yes. Because pediatric cardiac arrests may be considered a specific situation with many life-years at risk and only 1 historical cohort study looked at pTOR rules without showing convincing results, a new SysRev may find that TOR rules cannot be recommended for pediatric OHCAs. Accordingly, updating the SysRev is recommended. (Continued ) Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e251 Topic/PICO Year last updated Existing treatment recommendation RCTs since last review, n Observational studies since last review, n Key findings Sufficient data to warrant SysRev? CPR feedback devices during training (EIT 6404) 2020 We suggest the use of feedback devices that provide directive feedback on compression rate, depth, release, and hand position during CPR training (weak recommendation, low-certainty evidence). If feedback devices are not available, we suggest the use of tonal guidance (examples include music or metronome) during training to improve compression rate only (weak recommendation, low-certainty evidence). 7 3 All studies examined the effect of corrective feedback on objectively measured CPR quality as a primary outcome measure. The 5 RCTs demonstrate significant benefits of the CPR feedback device used during resuscitation courses, although the study populations were mostly novice health care professionals and laypeople. All studies focused on initial training rather than renewal course. Yes. The studies are consistent with the previous reviews and continue to support the use of CPR feedback devices during resuscitation training. Given the fairly large number of new studies, a formal SysRev with meta-analysis is recommended. CPR self-instruction vs instructorguided training (EIT 6406) 2020 We recommend instructor-led training (with manikin practice with feedback device) or the use of self-directed training with video kits (instructional video and manikin practice with feedback device) for the acquisition of CPR theory and skills in lay-adults and high school–aged (>10 y) children (strong recommendation, moderate quality of evidence). We recommend instructor-led training (with AED scenario and practice) or the use of self-directed video kits (instructional video with AED scenario) for the acquisition of AED theory and skills in lay-adults and high school–aged (>10 y) children (strong recommendation, low quality of evidence). We suggest BLS video education (without manikin practice) be used when instructor-led training or self-directed training with video kits (instructional video plus manikin with feedback device) is not accessible or when quantity over quality of BLS training is needed in adults and children (weak recommendation, weak quality of evidence). There was insufficient evidence to make a recommendation for gaming as a CPR or AED training method. There was insufficient evidence to suggest a treatment effect on bystander CPR rates or patient outcomes. 1 narrative review One 6-mo follow-up study of an RCT The narrative review suggests introducing self-directed learning, interactive digital, and abbreviated formats in communities and classroom teaching because CPR performance seems equivalent to traditional courses. The follow-up study reported still high willingness to perform CPR after 6 mo. No. The results of both of these studies support the current ILCOR CoSTR recommendation. Therefore, on the basis of the limited additional results, no new review was suggested. In situ simulationbased resuscitation training for health care professionals (EIT 6407) 2021 This EvUp does not enable a treatment recommendation to be made. 0 2 An in situ program for ECMO did not report significant changes in a before-and-after study. Another in situ interdisciplinary intraoperative code blue simulation training session on technical skills, nontechnical skills, and self-reported comfort reported significant improvements. No. On the basis of the limited additional evidence of this search, with no RCTs identified, this EvUp does not meet the criteria to trigger a formal systematic or ScopRev. ACLS indicates advanced cardiovascular life support; AED, automated external defibrillator; ALS, Advanced Life Support; app, application; ARREST, A Randomized Trial of Expedited Transfer to a Cardiac Arrest Centre for Non-ST Elevation Out-of-Hospital Cardiac Arrest; BLS, basic life support; CAC, cardiac arrest center; CoSTR, International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; CPR, cardiopulmonary resuscitation; ECMO, extracorporeal membrane oxygenation; EIT, Education, Implementation, and Teams; EMS, emergency medical services; EvUp, evidence update; IHCA, in-hospital cardiac arrest; ILCOR, International Liaison Committee on Resuscitation; MPS, mobile positioning system; NRT, Neonatal Resuscitation Training; OHCA, outof-hospital cardiac arrest; PICO, population, intervention, comparator, outcome; PICOST, population, intervention, comparator, outcome, study design, time frame; pTOR, pediatric termination of resuscitation; ROSC, return of spontaneous circulation; RCT, randomized controlled trial; ScopRev, scoping review; SysRev, systematic review; TM, text message; and TOR, termination of resuscitation. Table 34. Continued Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e252 number of studies identified, key findings, and whether a SysRev was deemed worthwhile provided. Complete EvUps can be found in Appendix B. FIRST AID Pulse Oximetry Use in the First Aid Setting (ScopRev) Rationale for Review Pulse oximetry has been used for monitoring of hospitalized patients at risk of hypoxemia and, more recently, for home use during the COVID-19 pandemic. The First Aid Task Force considered it timely to undertake a ScopRev to identify evidence relating to the use of pulse oximetry as a component of first aid assessment of acute symptoms associated with illness or injury. The full online CoSTR can be found on the ILCOR website.479 PICOST • Population: Adults and children in the out-of-hospital or home setting with an acute illness or injury • Intervention: Use of pulse oximetry in addition to standard first aid assessment • Comparators: Standard first aid assessment without the use of pulse oximetry • Outcomes: Any clinical outcome • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies), gray literature, social media and non–peer-reviewed studies, unpublished studies, conference abstracts, and trial protocols were eligible for inclusion. • Time frame: All years up to November 16, 2022 Summary of Evidence Our search identified 4204 unique articles, of which 16 underwent full-text review. All were ultimately excluded because they enrolled patients in home monitoring programs for a known, diagnosed infection or disease. Although the search strategy for this ScopRev was not designed to capture studies evaluating the accuracy of pulse oximetry based on skin pigmentation, some such studies were identified. In 1 study, there was a greater discrepancy between oxygen saturation as measured by pulse oximetry and that measured by blood gas (with pulse oximetry providing the higher number in general) in individuals identified as Black, Asian, or mixed ethnicity compared with those identified as White (Black, 1.8% [95% CI, 0.2–3.4], P=0.04; Asian, 1.9% [95% CI, 0.6–3.2], P=0.005; mixed ethnicity, 3.2% [95% CI, −0.1 to 6.6], P=0.06).480 In another study, Black patients had nearly 3 times the frequency of occult hypoxemia (hypoxemia not detected by pulse oximetry) as White patients.481 Task Force Insights The evidence identified in this ScopRev is not directly relevant to the first aid use of a pulse oximetry as a means of assessment for acute symptoms from illness or injury. Although there were reports of the early detection of asymptomatic hypoxemia in the out-of-hospital setting with pulse oximeters, we also identified concerns about device limitations, accuracy, reliability, and disparities in oximetry accuracy based on skin pigmentation. Although this search strategy was not designed to capture studies comparing the accuracy of pulse oximetry based on factors such as skin pigmentation, the First Aid Task Force is aware of multiple other studies evaluating this issue in addition to the ones identified. Findings generally support a small but statistically significant increase in occult hypoxemia in patients with darker skin.482–486 The First Aid Task Force expressed concerns about storage of oximeters in first aid kits, issues with readings due to movement and vibration, and outdoor use in settings with high humidity or extremes of temperature. Additional concern was expressed about the accuracy of oximeters sold as non–medical-use devices and used by the public to assist with self-identification of hypoxemia without training in their use, limitations, and interpretation of findings. Last, most home pulse oximetry monitors do not show the waveform, leading to challenges with interpreting the results. Although there is not sufficient evidence to support a recommendation for (or against) the use of a pulse oximeter by first aid providers, we recognize that pulse oximeters are readily available for purchase, may be found in some first aid kits, and may be in use by some first aid providers. There is inadequate evidence to pursue a SysRev at this time. Good Practice Statements First aid providers who use pulse oximeters for the assessment of acute illness or injuries should be proficient in their use and understand their limitations, including equipment factors, environmental considerations, and patient-specific factors that may produce inaccurate and unreliable readings (good practice statement). The use of a pulse oximeter for first aid assessment should not supersede or replace physical assessment (good practice statement). Use of Supplemental Oxygen in First Aid (ScopRev) Rationale for Review Although supplemental oxygen has been advocated as a beneficial treatment in several conditions, recent work has found evidence of harm with excessive oxygen administration in some patient populations such as those with suspected myocardial infarction.487 Because supplemental oxygen may be administered in these conditions Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e253 and others in the first aid setting, an understanding of the potential risks and benefits of supplemental oxygen administration is critical to first aid providers. The full online CoSTR can be found on the ILCOR website.488 PICOST • Population: Adults and children with signs or symptoms of shortness of breath, difficulty breathing, or hypoxia outside of a hospital • Intervention: Administration of oxygen by a first aid provider • Comparators: No administration of oxygen • Outcomes: Functional outcome at discharge, 30 days, 60 days, 180 days, and 1 year; survival only at discharge, 30 days, 60 days, 180 days, and 1 year; length of hospital stay, resolution of symptoms or signs, patient comfort, and therapeutic end points (eg, oxygenation, ventilation) • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies), case series and reports, gray literature, social media, non–peer-reviewed studies, unpublished studies, conference abstracts, and trial protocols were eligible for inclusion. Only English language articles were included. • Time frame: January 1, 2000, to July 1, 2022 Summary of Evidence Our search identified 2256 unique articles, of which 16 underwent full-text review. No articles directly addressed the review question. One cluster randomized trial compared EMS use of high-flow oxygen (defined as 8–10 L/min oxygen) with the use of titrated oxygen (titrated to an oxygen saturation of 88%–92%) for patients with acute chronic obstructive pulmonary disease (COPD) exacerbations and found a lower mortality rate in patients treated with titrated oxygen (relative risk, 0.42 [95% CI, 0.20–0.89]).489 Task Force Insights This ScopRev did not identify any direct evidence for or against the routine administration of oxygen in adults or children exhibiting signs or symptoms of shortness of breath, difficulty breathing, or hypoxia outside of a hospital. The current review has yielded evidence that oxygen therapy at an untitrated rate of 8 to 10 L/min is harmful in patients with acute exacerbations of COPD being treated by EMS, and oxygen needs to be titrated to the patient’s oxygen saturation in this setting. This has implications for first aid providers given that the 2015 CoSTR did not identify harms associated with the use of oxygen in patients displaying symptoms of shortness of breath.490 We acknowledge that recognition of acute exacerbations of COPD and the use of pulse oximetry may be beyond the skill set of many first aid providers. However, some organizations teaching advanced first aid or first aid oxygen courses may include teaching on the use of pulse oximetry, so there may be circumstances where the administration of supplemental oxygen by first aid providers is common practice. This review specifically excluded the use of supplemental oxygen in acute coronary syndrome,487 suspected stroke,491 drowning,3 and after ROSC following cardiac arrest57 because these indications have been covered in recent reviews. Given the potential for harm with untitrated oxygen, we suggest a good practice statement that supplements the 2015 CoSTR and includes the aforementioned considerations for patients with COPD. There is inadequate evidence to pursue a SysRev on this topic at this time. Prior Treatment Recommendations (2015) No recommendation was made; the confidence in the effect estimate is so low that the task force thinks a recommendation to change current practice is too speculative. 2023 Good Practice Statement If first aid providers, trained to use oxygen, are administering supplemental oxygen to a person with known COPD, they should titrate the supplemental oxygen to maintain an oxygen saturation by pulse oximetry between 88% and 92% (good practice statement). Recognition of Anaphylaxis (ScopRev) Rationale for Review Anaphylaxis is a time-sensitive condition for which early recognition and treatment with epinephrine are critical. It is unknown whether the presence or absence of any specific symptoms can assist first aid providers in appropriately identifying individuals with anaphylaxis. The full online CoSTR can be found on the ILCOR website.492 PICOST • Population: Adults and children experiencing anaphylaxis • Intervention: The description of any specific symptoms to the first aid provider • Comparators: Absence of any specific description • Outcomes: Recognition of anaphylaxis • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies), case series or reports, gray literature, social media publications, non–peer-reviewed studies, unpublished studies, conference abstracts and trial protocols were eligible for inclusion. All relevant publications in any language were included as long as there was an English abstract. • Time frame: All years to September 19, 2022 Summary of Evidence Our search identified 949 unique articles, of which 18 underwent full-text review. No articles directly addressed Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e254 the review question. Several of these studies reported an increase in knowledge of how to recognize anaphylaxis after educational interventions, viewing videos, health application (app) use, and coaching.493–502 Other identified studies examined the effectiveness of action plans503,504 and educational interventions to improve recognition of anaphylaxis505–508 and the relationship between education on anaphylaxis recognition and the use of epinephrine.509 Task Force Insights Although none of the studies identified specific signs or symptoms that may be used by first aid providers in the identification of anaphylaxis, several surveys reported improvement in the ability to recognize anaphylaxis immediately after individual or community-level educational engagements. New initiatives to improve recognition and management of anaphylaxis should be studied to evaluate their effectiveness and efficiency. Previous literature has identified different factors associated with underuse of epinephrine in anaphylaxis.510,511 Recognition of anaphylaxis is one of the identified factors that can reduce the delay in the administration of epinephrine when it is available, although evidence for this is limited. Recognition of anaphylaxis is not the only barrier to the first aid use of epinephrine autoinjectors. The high cost of epinephrine autoinjectors, lack of availability in some settings, lack of epinephrine use even when it is available, incorrect administration technique, and fear of harm with administration are also barriers. There is inadequate evidence to pursue a SysRev of this topic at this time. Prior Treatment Recommendation (2010), Unchanged First aid providers should not be expected to recognize the signs and symptoms of anaphylaxis without repeated episodes of training and encounters with individuals with anaphylaxis.512 Potential Harms From Bronchodilator Administration (ScopRev) Rationale for Review People with asthma exacerbations benefit from administration of bronchodilators. However, it is unknown whether first aid providers can appropriately identify asthma exacerbations, and it is unknown whether bronchodilators could result in harm if administered to individuals with undifferentiated respiratory symptoms. The full online CoSTR can be found on the ILCOR website.513 PICOST • Population: Adults and children in any setting with acute undifferentiated respiratory problems • Intervention: Administration of any type of inhaled bronchodilator (eg, β-agonists, anticholinergics) • Comparators: No administration of an inhaled bronchodilator • Outcomes: Survival, dysrhythmia, cardiac ischemia, hypokalemia, need for emergency department treatment, need for hospitalization, or time to treatment • Study designs: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) and case series were eligible for inclusion. Only English language studies were included. • Time frame: All years to November 2, 2022 Summary of Evidence Our search identified 403 unique articles, of which 15 underwent full-text review. Thirteen articles were identified that reported adverse effects of short-acting inhaled bronchodilators that could be available to first aid providers caring for patients with reactive airway disease; however, none directly addressed the PICOST. Examples of identified adverse effects were tachycardia, arrhythmias, tremor, dizziness, and a decrease in serum potassium concentrations. Bronchodilators included albuterol (salbutamol) through a nebulizer, albuterol (salbutamol) through a metered dose inhaler, fenoterol through a metered dose inhaler, ipratropium through a nebulizer, and metaproterenol through a nebulizer. Tachycardia was noted with albuterol; however, the increase in heart rate was less when albuterol was delivered through metered dose inhaler compared with delivery by nebulizer (MD, −6.47 bpm [95% CI, −11.69 to −1.25]; P=0.02).514 Other studies noted palpitations (salbutamol)515 and premature ventricular contractions (fenoterol and albuterol)516 after the use of inhaled bronchodilators. Multiple studies516–519 documented a decrease in serum potassium concentration after the use of short-acting β-agonists, although these were typically mild (mean decrease, 0.54 mmol/L in 1 study and 0.52 mmol/L in another)517,520 and of uncertain clinical significance. Case reports521–524 describe multiple side effects in patients exposed to short-acting bronchodilators. A case of unilateral mydriasis developed after nebulized ipratropium came into contact with an eye, resulting in the person receiving a CT scan of the brain to evaluate for intracranial abnormalities.521 Severe bronchospasm occurred after exposure to an albuterol inhaler and nebulizer treatment.522 Last, 1 patient developed takotsubo cardiomyopathy that was associated with repetitive use of an albuterol inhaler.524 Task Force Insights Most studies included patients with reactive airway diseases. An increase in heart rate (eg, by an average of 13 bpm in 1 study of metaproterenol) could cause myocardial ischemia in a patient with cardiac disease or could Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e255 exacerbate tachyarrhythmias such as supraventricular tachycardia.525 Inhaled short-acting β-agonists are associated with a decrease in plasma potassium values, typically by <1 mmol/L (eg, a mean decrease of 0.54 mmol/L in 1 study and 0.52 mmol/L in another).517,520 Whether these adverse effects outweigh the potential benefit of bronchodilators is unknown. There is inadequate evidence to undertake a SysRev on harm of bronchodilators and therefore inadequate evidence to amend the 2015 CoSTR on the use of bronchodilators in individuals with asthma. Prior Treatment Recommendation (2015), Unchanged When an individual with asthma is experiencing difficulty breathing, we suggest that trained first aid providers assist the individual with administration of a bronchodilator (weak recommendation, very low–certainty evidence).526 First Aid Topics Reviewed by EvUps Topics reviewed by EvUps are summarized in Table 35, which provides the PICO, existing treatment recommendation, number of studies identified, key findings, and whether a SysRev was deemed worthwhile. Complete EvUps can be found in Appendix B. ARTICLE INFORMATION The American Heart Association, the European Resuscitation Council, and the International Liaison Committee on Resuscitation make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This document was approved by the American Heart Association Science Advisory and Coordinating Committee on June 30, 2023; the American Heart Association Executive Committee on August 4, 2023; and the ILCOR Board on August 24, 2023. A copy of the document is available at https://professional. heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. The American Heart Association requests that this document be cited as follows: Berg KM, Bray JE, Ng K-C, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, et al. 2023 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2023;148:e187–e280. doi: 10.1161/CIR.0000000000001179 The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.” Acknowledgments The writing group acknowledges Jack Billi, Samantha Johnson, Eddy Lang, and Veronica Zamora. Collaborators Roberto Barcala-Furelos; Stephen B. Beerman; Marlies Bruckner; Maaret Castrén; ShuLing Chong; Andreas Claesson; Cody L. Dunne; Emer Finan; Tatsuma Fukuda; Saptharishi Lalgudi Ganesan; Callum Gately; Aecio Gois; Seth Gray; Louis P. Halamek; Amber V. Hoover; Cameron Hurst; Justin Josephsen; Louise Kollander; C. Omar Kamlin; Mirjam Kool; Lei Li; Thomas S. Mecrow; William Montgomery; Patrick Ristau; Muralidharan Jayashree; Andrew Schmidt; Tommaso Scquizzato; Jeroen Seesink; Justin Sempsrott; Anne Lee Solevåg; Marya L. Strand; David Szpilman; Edgardo Szyld; Ogilvie Thom; Joshua M. Tobin; Jacinta Trang; Jonathon Webber; Hannah K. Webster; and Michelle Wellsford Table 35. First Aid Topics Reviewed by EvUps Topic/PICO Year last updated Existing treatment recommendation RCTs since last review, n Observational studies since last review, n Key findings Sufficient data to warrant SysRev? Cervical spinal motion restriction (FA7334) 2015 We suggest against the use of cervical collars by first aid providers (weak recommendation, very low–quality evidence). 3 5 Given limited additional information on spinal motion restriction identified in this EvUp, the task force did not feel that there was sufficient information to pursue a systematic review or the reconsideration of current treatment recommendations. No Hemostatic agents for life-threatening external bleeding (FA7334) 2020 We suggest that first aid providers use a hemostatic dressing with direct pressure as opposed to direct pressure alone for severe, life-threatening external bleeding (weak recommendation, very low-certainty of evidence). For the treatment of severe, life-threatening external bleeding by first aid providers, due to very limited data and very low confidence in effect estimates, we are unable to recommend the use of any one specific type of hemostatic dressing compared with another. None None Most new articles are on postsurgery bleeding or malignant ulcers. No EvUp indicates evidence update; PICO, population, intervention, comparator, outcome; and RCT, randomized controlled trial. Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e256 Disclosures Writing Group Disclosures Writing group member Employment Research grant Other research support Speakers’ bureau/honoraria Expert witness Ownership interest Consultant/ advisory board Other Katherine M. Berg Beth Israel Deaconess Medical Center None None None None None AHA† None Jerry P. Nolan Warwick Medical School, University of Warwick (United Kingdom) NIHR grants* None None None None None None Cristian AbelairasGómes Faculty of Education Sciences (Spain) None None None None None None None Jason Acworth University of Queensland, Children’s Health Clinical Unit (Australia) None None None None None None None Lars W. Andersen Aarhus University (Denmark) None None None None None None None Dianne L. Atkins University of Iowa None None None None None None None David C. Berry Saginaw Valley State University None None None None None None None Farhan Bhanji McGill University (Canada) None None None None None None None Joost Bierens Vrije Universiteit Brussel/UZ Brussel (Belgium) None None None 2022 Expert witness plaintiff* None Royal Society to Rescue People from Drowning*; Royal Dutch Lifeboat Institution* None Vere Borra Belgian Red Cross None None None None None None None Bernd W. Böttiger University Hospital of Cologne (Germany) None None Forum für medizinische Fortbildun*; Baxalta Deutschland GmbH*; ZOLL Medical Deutschland GmbH*; C.R. Bard GmbH*; GS Elektromedizinische Geräte G. Stemple GmbH*; Novartis Pharma GmbH*; Philips GmbH Market DACH*; Bioscience Valuation BSV GmbH* None None None Treasurer of the European Resuscitation Council (ERC); founder of the ERC Research NET; chairman of the German Resuscitation Council (GRC); member of the Advanced Life Support (ALS) Task Force of ILCOR; member of the Executive Committee of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI); founder of the “Deutsche Stiftung Wiederbelebung”; Federal Medical Advisor of the German Red Cross (DRK); member of the Advisory Board of the “Deutsche Herzstiftung”; coeditor of Resuscitation, editor of the Journal Notfall+Rettungsmedizin; coeditor of the Brazilian Journal of Anesthesiology* Richard N. Bradley Self-employed None None None None None None None Janet E. Bray Monash University (Australia) None None None None None None None Jan Breckwoldt University Hospital of Zurich (Switzerland) None None None None None Swiss Institute for Medical Education (SIWF/ ISFM)* None (Continued ) Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e257 Writing group member Employment Research grant Other research support Speakers’ bureau/honoraria Expert witness Ownership interest Consultant/ advisory board Other Jestin N. Carlson Allegheny Health Network None None None None None AHA/RQI Partners* None Pascal Cassan International Federation of Red Cross and Red Crescent Natiola Societies (France) None None None None None None None Wei-Tien Chang National Taiwan University Hospital and College of Medicine (Taiwan) None None None None None None None Nathan P. Charlton University of Virginia None None None None None None None Adam Cheng Alberta Children’s Hospital (Canada) None None None None The Debriefing Academy† None None Sung Phil Chung Gangnam Severance Hospital, Yonsei University (Republic of Korea) None None None None None None None Julie Considine Deakin University (Australia) National Health and Medical Research Council† None None None None None None Daniela T. Costa-Nobre Universidade Federal de Sao Paulo (Brazil) None None None None None None None Keith Couper University of Warwick (United Kingdom) NIHR and Resuscitation Council UK† None None None None None University Hospitals Birmingham NHS Foundation Trust†; University of Warwick† Thomaz Bittencourt Couto Hospital Israelita Albert Einstein/ Universidade de São Paulo (Brazil) None None None None None None None Katie N. Dainty North York General Hospital (Canada) None None None None None None None Vihara Dassanayake University of Colombo (Sri Lanka) None None None None None None None Peter G. Davis Royal Women’s Hospital (Australia) None None None None None None None Jennifer A. Dawson The Royal Women’s Hospital (Australia) None None None None None None None Maria Fernanda de Almeida Universidade Federal de Sao Paulo (Brazil) None None None None None None None Allan R. De Caen University of Alberta (Canada) None None None None None None None Charles D. Deakin University Hospital Southampton NHS Foundation Trust (United Kingdom) None None None None None None None Bridget Dicker St. John (New Zealand) https://www.manaakimanawa.ac.nz/putahimanawa/†; Heart Core Equity Grant, https://www.hrc.govt. nz/news-and-events/ more-122m-awarded-healthdelivery-research†; Health Research Council, Activation Grant, https://www.hrc. govt.nz/news-and-events/ more-122m-awarded-healthdelivery-research†:Health Research Council, Activation Grant, St. John EMS Bequests Donation*; Rapid Response Revival, CellAED manufacturer* None None None None None Emergency Medical Service New Zealand†; Auckland University of Technology† Writing Group Disclosures Continued (Continued ) Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e258 Writing group member Employment Research grant Other research support Speakers’ bureau/honoraria Expert witness Ownership interest Consultant/ advisory board Other Therese Djärv Karolinska Institutet (Sweden) None None None None None None None Matthew J. Douma University of Alberta (Canada) None None None None None None None Ian R. Drennan University of Toronto (Canada) None None None None None None None Kathryn Eastwood Monash University (Australia) Heart Foundation of Australia† None None None None None None Walid El-Naggar Dalhousie University (Canada) Coinvestigator;* collaborator*; principal investigator† None None None None None None Jorge G. Fabres Pontificia Universidad Catolica de Chile (Chile) None None None None None None None Joe Fawke University Hospitals Leicester NHS Trust (United Kingdom) None None None None None None None Nino Fijacko University of Maribor, Faculty of Health Science (Slovenia) None None None None None None None Judith C. Finn Curtin University (Australia) National Health and Medical Research Council (Australia)† None None None None None None Gustavo E. Flores Emergency & Critical Care Trainings LLC None None None None None None None Elizabeth E. Foglia Children’s Hospital of Philadelphia NIH†; Chiesi† None None None None Chiesi USA†; Medtronic* None Frederik Folke Gentofte University Hospital, Hellerup (Denmark) NovoNordisk Foundation (NNF19OC0055142, Research grant for improving cardiac arrest survival)* None None None None None None Elaine Gilfoyle Hospital for Sick Children (Canada) None None None None None None None Craig A. Goolsby Harbor–UCLA Medical Center None None None None None None None Asger Granfeldt Aarhus University Hospital (Denmark) None None None None None Noorik Pharmaceuticals† None Robert Greif Bern University Hospital, University of Bern (Switzerland) None None None None None None None Anne-Marie Guerguerian The Hospital for Sick Children (Canada) None None None None None None None Ruth Guinsburg Federal University of Sao Paulo (Brazil) None None None None None None None Tetsuo Hatanaka Emergency Life Saving Technique Academy (Japan) None None None None None None None Karen G. Hirsch Stanford University None None None None None None None Mathias J. Holmberg Aarhus University Hospital (Denmark) None None None None None None None Shigeharu Hosono Jichi Medical University, Saitama Medical Center (Japan) None None None None None None None Ming-Ju Hsieh National Taiwan University Hospital (Taiwan) None None None None None None None Cindy H. Hsu University of Michigan None None None None None None None Writing Group Disclosures Continued (Continued ) Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e259 Writing group member Employment Research grant Other research support Speakers’ bureau/honoraria Expert witness Ownership interest Consultant/ advisory board Other Takanari Ikeyama Aichi Children’s Health and Medical Center (Japan) None None None None None None None Tetsuya Isayama Showa General Hospital (Japan) None None None None None None None Nicholas J. Johnson University of Washington/Harborview Medical Center NIH†; Centers for Disease Control and Prevention†; Department of Defense†; University of Washington Royalty Research Fund† None None None None None None Vishal S. Kapadia UT Southwestern NIH† None None None None None None Mandira Daripa Kawakami Universidade Federal de São Paulo (Brazil) None None None None None None None Han-Suk Kim Seoul National University College of Medicine (Republic of Korea) None None None None None None None Monica E. Kleinman Boston Children’s Hospital None None None None None None None David A. Kloeck Resuscitation Council of Southern Africa (South Africa) None None None None None None None Peter Kudenchuk University of Washington Medical Center NIH* None None None None None None Amy Kule American Red Cross None None None None None None None Anthony T. Lagina Wayne State University None None None None None None None Kasper G. Lauridsen Randers Regional Hospital (Denmark) None None None None None None None Eric J. Lavonas Denver Health None None None None None None None Henry C. Lee Stanford University None None None None None None None Helen G. Liley The University of Queensland (Australia) None None None None None None None Yiqun Lin Alberta Children’s Hospital (Canada) None None None None None None None Andrew S. Lockey European Resuscitation Council (United Kingdom) None None None None None None None Finlay Macneil ANZCOR None None None None SHL† None None Ian K. Maconochie Imperial College NHS Healthcare Trust and Centre for Reviews and Dissemination, St. Mary’s Hospital (United Kingdom) None None None None None None None R. John Madar National Health Service (United Kingdom) None None None None None None None Carolina Malta Hansen Copenhagen EMS (Denmark) TrygFonden†; Helsefonden†; Laerdal Foundation†; NIH*; ILCOR*;Zoll† None None None None Duke Clinical Research Institute† None Siobhan Masterson Irish National Ambulance Service (Ireland) None None None None None None None Writing Group Disclosures Continued (Continued ) Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e266 REFERENCES 1. International Liaison Committee on Resuscitation. ILCOR website. Accessed February 20, 2023. https://ilcor.org/ 2. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, et al. GRADE guidelines: 1, introduction–GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64:383–394. doi: 10.1016/j.jclinepi.2010.04.026 3. Bierens J, Abelairas-Gomez C, Barcala Furelos R, Beerman S, Claesson A, Dunne C, Elsenga HE, Morgan P, Mecrow T, Pereira JC, et al. Resuscitation and emergency care in drowning: a scoping review. Resuscitation. 2021;162:205–217. doi: 10.1016/j.resuscitation.2021.01.033 4. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castren M, Chung SP, Considine J, Couper K, Escalante R, et al; Adult Basic Life Support Collaborators. Adult basic life support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A35–A79. doi: 10.1016/j.resuscitation.2020.09.010 5. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castren M, Chung SP, Considine J, Couper K, Escalante R, et al; Adult Basic Life Support Collaborators. Adult basic life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142:S41– S91. doi: 10.1161/CIR.0000000000000892 6. Barcala-Furelos R, Schmidt A, Webber J, Perkins G, Bierens J, Bray J; International Liaison Committee on Resuscitation Basic Life Support Task Force. Immediate resuscitation in-water or delaying until on land strategies for drowning: Consensus on Science With Treatment Recommendations. Accessed January 15, 2023. https://costr.ilcor.org/document/immediateresuscitation-in-water-or-delaying-on-land-in-drowning-bls-tf-sr 7. Szpilman D, Soares M. In-water resuscitation: is it worthwhile? Resuscitation. 2004;63:25–31. doi: 10.1016/j.resuscitation.2004.03.017 8. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, part 2: adult basic life support. Resuscitation. 2005;67:187–201. doi: 10.1016/j.resuscitation.2005.09.016 9. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, part 2: adult basic life support. Circulation. 2005;112:III-5-III-16. doi: 10.1161/CIRCULATIONAHA.105.166472 10. Szpilman D, Morgan PJ. Management for the drowning patient. Chest. 2021;159:1473–1483. doi: 10.1016/j.chest.2020.10.007 11. March NF, Matthews RC. New techniques in external cardiac compressions: aquatic cardiopulmonary resuscitation. JAMA. 1980;244:1229–1232. 12. Winkler BE, Eff AM, Ehrmann U, Eff S, Koch A, Kaehler W, Georgieff M, Muth CM. Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: a crossover manikin study. Prehosp Emerg Care. 2013;17:409–415. doi: 10.3109/10903127.2013.792892 13. Winkler BE, Eff AM, Eff S, Ehrmann U, Koch A, Kahler W, Muth CM. Efficacy of ventilation and ventilation adjuncts during in-water-resuscitation: a randomized cross-over trial. Resuscitation. 2013;84:1137–1142. doi: 10.1016/j.resuscitation.2013.02.006 14. Perkins GD. In-water resuscitation: a pilot evaluation. Resuscitation. 2005;65:321–324. doi: 10.1016/j.resuscitation.2004.12.002 15. Manolios N, Mackie I. Drowning and near-drowning on Australian beaches patrolled by life-savers: a 10-year study, 1973-1983. Med J Aust. 1988;148:165–171. 16. Lungwitz YP, Nussbaum BL, Paulat K, Muth CM, Kranke P, Winkler BE. A novel rescue-tube device for in-water resuscitation. Aerosp Med Hum Perform. 2015;86:379–385. doi: 10.3357/AMHP.4133.2015 17. Seesink J, Nieuwenburg SAV, van der Linden T, Bierens J. Circumstances, outcome and quality of cardiopulmonary resuscitation by lifeboat crews. Resuscitation. 2019;142:104–110. doi: 10.1016/j.resuscitation.2019.07.012 18. Fungueirino-Suarez R, Barcala-Furelos R, Gonzalez-Fermoso M, Martinez-Isasi S, Fernandez-Mendez F, Gonzalez-Salvado V, Navarro-Paton R, Rodriguez-Nunez A. Coastal fishermen as lifesavers while sailing at high speed: a crossover study. Biomed Res Int. 2018;2018:Artn 2747046. doi: 10.1155/2018/2747046 19. Tipton M, David G, Eglin C, Golden F. Basic life support on small boats at sea. Resuscitation. 2007;75:332–337. doi: 10.1016/j.resuscitation.2007.04.027 20. Venema AM, Sahinovic MM, Ramaker AJDWR, van de Riet YN, Absalom AR, Wietasch JKG. Performance of basic life support by lifeboat crewmembers while wearing a survival suit and life vest: a randomized controlled trial. Front Public Health. 2021;9:ARTN 666553. doi: 10.3389/fpubh.2021.666553 21. Barcala-Furelos R, Abelairas-Gomez C, Palacios-Aguilar J, Rey E, Costas-Veiga J, Lopez-Garcia S, Rodriguez-Nunez A. Can surf-lifeguards perform a quality cardiopulmonary resuscitation sailing on a lifeboat? A quasi-experimental study. Emerg Med J. 2017;34:370. doi: 10.1136/emermed-2016-205952 22. Barcala-Furelos R, Abelairas-Gómez C, Alonso-Calvete A, Cano-Noguera F, Carballo-Fazanes A, Martínez-Isasi S, Rodríguez-Núñez A. Safe onboat resuscitation by lifeguards in COVID-19 era: a pilot study comparing three sets of personal protective equipment. Prehosp Disaster Med. 2021;36:163–169. doi: 10.1017/S1049023X2100011X 23. Idris AH, Bierens J, Perkins GD, Wenzel V, Nadkarni V, Morley P, Warner DS, Topjian A, Venema AM, Branche CM, et al. 2015 Revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related resuscitation: an ILCOR advisory statement. Resuscitation. 2017;118:147– 158. doi: 10.1016/j.resuscitation.2017.05.028 24. Idris AH, Bierens J, Perkins GD, Wenzel V, Nadkarni V, Morley P, Warner DS, Topjian A, Venema AM, Branche CM, et al. 2015 Revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related resuscitation: an ILCOR advisory statement. Circ Cardiovasc Qual Outcomes. 2017;10:e000024. doi: 10.1161/HCQ.0000000000000024 25. Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association [published corrections appear in Circulation. 2013;128:e120 and Circulation. 2013;128:e408]. Circulation. 2013;128:417–435. doi: 10.1161/CIR.0b013e31829d8654 26. Haywood K, Whitehead L, Nadkarni VM, Achana F, Beesems S, Bottiger BW, Brooks A, Castren M, Ong ME, Hazinski MF, et al; COSCA Collaborators. COSCA (Core Outcome Set for Cardiac Arrest) in adults: an advisory statement from the International Liaison Committee on Resuscitation. Circulation. 2018;137:e783–e801. doi: 10.1161/CIR.0000000000000562 27. Haywood K, Whitehead L, Nadkarni VM, Achana F, Beesems S, Bottiger BW, Brooks A, Castren M, Ong MEH, Hazinski MF, et al; COSCA Collaborators. COSCA (Core Outcome Set for Cardiac Arrest) in adults: an advisory statement from the International Liaison Committee on Resuscitation. Resuscitation. 2018;127:147–163. doi: 10.1016/j.resuscitation.2018.03.022 28. Beerman S, Beerman T, Fukuda T, Bierens J, Olasveengen T, Bray J, Morley PT, Perkins GD; International Liaison Committee on Resuscitation Basic Life Support Task Force. AED first vs CPR first for drowning: Consensus on Science With Treatment Recommendations. Accessed January 15, 2022. https://costr.ilcor.org/document/aed-first-vs-cpr-first-in-cardiac-arrestfollowing-drowning-bls-856 29. Bierens JJ, Lunetta P, Tipton M, Warner DS. Physiology of drowning: a review. Physiology (Bethesda). 2016;31:147–166. doi: 10.1152/physiol.00002.2015 30. Kiyohara K, Sado J, Matsuyama T, Nishiyama C, Kobayashi D, Kiguchi T, Hayashida S, Kitamura Y, Sobue T, Nakata K, et al. Out-of-hospital cardiac arrests during exercise among urban inhabitants in Japan: insights from a population-based registry of Osaka City. Resuscitation. 2017;117:14–17. doi: 10.1016/j.resuscitation.2017.05.025 31. Holmberg MJ, Vognsen M, Andersen MS, Donnino MW, Andersen LW. Bystander automated external defibrillator use and clinical outcomes after out-of-hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2017;120:77–87. doi: 10.1016/j.resuscitation.2017.09.003 32. Abelairas-Gómez C, Tobin JM, Jayashree M, Bierens J, Olasveengen T, Bray J, Morley PT, Perkins GD; International Liaison Committee on Resuscitation Basic Life Support Task Force. Ventilation strategies (with vs without equipment) following drowning: Consensus on Science With Treatment Recommendations. Accessed January 15, 2023. https://costr.ilcor.org/document/ ventilation-with-vs-without-equipment-before-hospital-arrival-followingdrowning-bls-tfsr 33. Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, Aickin R, Bhanji F, Donnino MW, Mancini ME, et al. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2019;140:e826–e880. doi: 10.1161/CIR.0000000000000734 34. Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, Aickin R, Bhanji F, Donnino MW, Mancini ME, et al. 2019 International Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e267 Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2019;145:95–150. doi: 10.1016/j.resuscitation.2019.10.016 35. Ryan KM, Bui MD, Dugas JN, Zvonar I, Tobin JM. Impact of prehospital airway interventions on outcome in cardiac arrest following drowning: a study from the CARES Surveillance Group. Resuscitation. 2021;163:130–135. doi: 10.1016/j.resuscitation.2020.12.027 36. Baker PA, Webber JB. Failure to ventilate with supraglottic airways after drowning. Anaesth Intensive Care. 2011;39:675–677. doi: 10.1177/0310057X1103900423 37. Joanknecht L, Argent AC, van Dijk M, van As AB. Childhood drowning in South Africa: local data should inform prevention strategies. Pediatr Surg Int. 2015;31:123–130. doi: 10.1007/s00383-014-3637-0 38. Kieboom JK, Verkade HJ, Burgerhof JG, Bierens JJ, Rheenen PF, Kneyber MC, Albers MJ. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study. BMJ. 2015;350:h418. doi: 10.1136/bmj.h418 39. Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian AM, Nadkarni VM, Ng KC, Nuthall GA, et al; Pediatric Life Support Collaborators. Pediatric life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A120– A155. doi: 10.1016/j.resuscitation.2020.09.013 40. Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian AM, Nadkarni VM, Ng KC, Nuthall GA, et al; Pediatric Life Support Collaborators. Pediatric life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142:S140– S184. doi: 10.1161/CIR.0000000000000894 41. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castrén M, Chung SP, Considine J, Couper K, Escalante R, et al; Adult Basic Life Support Collaborators. Adult basic life support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A35–A79. doi: 10.1016/j.resuscitation.2020.09.010 42. Olasveengen TM, Semeraro F, Ristagno G, Castren M, Handley A, Kuzovlev A, Monsieurs KG, Raffay V, Smyth M, Soar J, et al. European Resuscitation Council Guidelines 2021: basic life support. Resuscitation. 2021;161:98– 114. doi: 10.1016/j.resuscitation.2021.02.009 43. Abelairas-Gomez C, Tipton MJ, Gonzalez-Salvado V, Bierens J. Drowning: epidemiology, prevention, pathophysiology, resuscitation, and hospital treatment. Emergencias. 2019;31:270–280. 44. Sempsrott J, Szpilman D, Liu L, Bierens J, Bray J, Perkins GD, International Liaison Committee on Resuscitation Basic Life Support Task Force. Compression-only CPR vs standard CPR with compressions and ventilations following drowning: Consensus on Science With Treatment Recommendations. Accessed January 15, 2023. https://costr.ilcor.org/document/ chest-compression-cpr-versus-conventional-cpr-in-drowning-bls-tfsr 45. Fukuda T, Ohashi-Fukuda N, Hayashida K, Kondo Y, Kukita I. Bystanderinitiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning. Resuscitation. 2019;145:166–174. doi: 10.1016/j.resuscitation.2019.08.026 46. Tobin JM, Ramos WD, Greenshields J, Dickinson S, Rossano JW, Wernicki PG, Markenson D, Vellano K, McNally B; CARES Surveillance Group. Outcome of conventional bystander cardiopulmonary resuscitation in cardiac arrest following drowning. Prehosp Disaster Med. 2020;35:141–147. doi: 10.1017/S1049023X20000060 47. Bray JE, Smith K, Case R, Cartledge S, Straney L, Finn J. Public cardiopulmonary resuscitation training rates and awareness of hands-only cardiopulmonary resuscitation: a cross-sectional survey of Victorians. Emerg Med Australas. 2017;29:158–164. doi: 10.1111/1742-6723.12720 48. Gräsner J-T, Wnent J, Herlitz J, Perkins GD, Lefering R, Tjelmeland I, Koster RW, Masterson S, Rossell-Ortiz F, Maurer H, et al. Survival after out-of-hospital cardiac arrest in Europe: results of the EuReCa TWO study. Resuscitation. 2020;148:218–226. doi: 10.1016/j.resuscitation.2019.12.042 49. Lagina AT, Claesson A, Bierens J, Olasveengen T, Bray J, Morley PT, Perkins GD; International Liaison Committee on Resuscitation Basic Life Support Task Force. Public access to defibrillation following drowning: Consensus on Science With Treatment Recommendations. Accessed January 15, 2023. https://costr.ilcor.org/document/implementation-of-pad-programs-fordrowning-bls 50. Brooks SC, Clegg GR, Bray J, Deakin CD, Perkins GD, Ringh M, Smith CM, Link MS, Merchant RM, Pezo-Morales J, et al; International Liaison Committee on Resuscitation. Optimizing outcomes after out-ofhospital cardiac arrest with innovative approaches to public-access defibrillation: a scientific statement from the International Liaison Committee on Resuscitation. Resuscitation. 2022;172:204–228. doi: 10.1016/j.resuscitation.2021.11.032 51. Brooks SC, Clegg GR, Bray J, Deakin CD, Perkins GD, Ringh M, Smith CM, Link MS, Merchant RM, Pezo-Morales J, et al; on behalf of the International Liaison Committee on Resuscitation. Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to publicaccess defibrillation: a scientific statement from the International Liaison Committee on Resuscitation. Circulation. 2022;145:e776–e801. doi: 10.1161/CIR.0000000000001013 52. Seesink J, Thom O, Johnson S, Bierens J, Olasveengen T, Bray J, Morley PT, Perkins GD; International Liaison Committee on Resuscitation Basic Life Support Task Force. Oxygen administration following drowning: Consensus on Science With Treatment Recommendations. Accessed January 15, 2023. https://costr.ilcor.org/document/oxygen-administration-followingdrowning-bls-856 53. Bernard SA, Bray JE, Smith K, Stephenson M, Finn J, Grantham H, Hein C, Masters S, Stub D, Perkins GD, et al; EXACT Investigators. Effect of lower vs higher oxygen saturation targets on survival to hospital discharge among patients resuscitated after out-of-hospital cardiac arrest: the EXACT randomized clinical trial. JAMA. 2022;328:1818–1826. doi: 10.1001/jama.2022.17701 54. Holbery-Morgan L, Carew J, Angel C, Simpson N, Steinfort D, Radford S, Murphy M, Douglas N, Johnson D. Feasibility of pulse oximetry after water immersion. Resusc Plus. 2021;7:100147. doi: 10.1016/j.resplu.2021.100147 55. Montenij LJ, de Vries W, Schwarte L, Bierens JJ. Feasibility of pulse oximetry in the initial prehospital management of victims of drowning: a preliminary study. Resuscitation. 2011;82:1235–1238. doi: 10.1016/j.resuscitation.2011.04.019 56. Shi C, Goodall M, Dumville J, Hill J, Norman G, Hamer O, Clegg A, Watkins CL, Georgiou G, Hodkinson A, et al. The effects of skin pigmentation on the accuracy of pulse oximetry in measuring oxygen saturation: a systematic review and meta-analysis. BMC Med. 2022;20:267. doi: 10.1101/2022.02.16.22271062 57. Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, et al; Collaborators. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation. 2022;181:208–288. doi: 10.1016/j.resuscitation.2022.10.005 58. Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, et al; Collaborators. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2022;146:e483–e557. doi: 10.1161/CIR.0000000000001095 59. Couper K, Taylor-Phillips S, Grove A, Freeman K, Osokogu O, Court R, Mehrabian A, Morley PT, Nolan JP, Soar J, et al. COVID-19 in cardiac arrest and infection risk to rescuers: a systematic review. Resuscitation. 2020;151:59–66. doi: 10.1016/j.resuscitation.2020.04.022 60. Chung SP, Nehme Z, Johnson NJ, Lagina A, Bray J; International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force. Effects of personal protective equipment on cardiopulmonary resuscitation quality and outcomes: a systematic review. Resusc Plus. 2023;14:100398. doi: 10.1016/j.resplu.2023.100398 61. Chung SP, Nehme Z, Lagina A, Johnson N, Bray J; International Liaison Committee on Resuscitation Basic Life Support Task Force. CPR by rescuers wearing PPE vs no PPE for cardiac arrest in adults and children: Consensus on Science With Treatment Recommendations. Accessed January 15, 2023. https://costr.ilcor.org/document/cpr-by-rescuers-wearing-ppebls-tfsr 62. Ko HY, Park JE, Jeong DU, Shin TG, Sim MS, Jo IJ, Lee GT, Hwang SY. Impact of personal protective equipment on out-of-hospital cardiac arrest resuscitation in coronavirus pandemic. Medicina (Kaunas). 2021;57:1291. doi: 10.3390/medicina57121291 63. Kienbacher CL, Grafeneder J, Tscherny K, Krammel M, Fuhrmann V, Niederer M, Neudorfsky S, Herbich K, Schreiber W, Herkner H, et al. The use of personal protection equipment does not impair the quality of cardiopulmonary resuscitation: a prospective triple-cross over randomised Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e268 controlled non-inferiority trial. Resuscitation. 2021;160:79–83. doi: 10.1016/j.resuscitation.2021.01.021 64. Mormando G, Paganini M, Alexopoulos C, Savino S, Bortoli N, Pomiato D, Graziano A, Navalesi P, Fabris F. Life-saving procedures performed while wearing CBRNe Personal protective equipment: a mannequin randomized trial. Simul Healthc. 2021;16:e200–e205. doi: 10.1097/SIH.0000000000000540 65. Rauch S, van Veelen MJ, Oberhammer R, Dal Cappello T, Roveri G, Gruber E, Strapazzon G. Effect of wearing personal protective equipment (PPE) on CPR quality in times of the COVID-19 pandemic: a simulation, randomised crossover trial. J Clin Med. 2021;10:1728. doi: 10.3390/jcm10081728 66. Chen J, Lu KZ, Yi B, Chen Y. Chest compression with personal protective equipment during cardiopulmonary resuscitation: a randomized crossover simulation study. Medicine (Baltimore). 2016;95:e3262. doi: 10.1097/MD.0000000000003262 67. Kim TH, Kim CH, Shin SD, Haam S. Influence of personal protective equipment on the performance of life-saving interventions by emergency medical service personnel. Simulation. 2016;92:893–898. doi: 10.1177/0037549716662322 68. Fernández-Méndez M, Otero-Agra M, Fernández-Méndez F, Martínez-Isasi S, Santos-Folgar M, Barcala-Furelos R, Rodríguez-Núñez A. Analysis of physiological response during cardiopulmonary resuscitation with personal protective equipment: a randomized crossover study. Int J Environ Res Public Health. 2021;18:7093. doi: 10.3390/ijerph18137093 69. Hacımustafaoğlu M, Çağlar A, Öztürk B, Kaçer I, Öztürk K. The effect of personal protective equipment on cardiac compression quality. African J Emerg Med. 2021;11:385–389. doi: 10.1016/j.afjem.2021.07.004 70. Serin S, Caglar B. The effect of different personal protective equipment masks on health care workers’ cardiopulmonary resuscitation performance during the Covid-19 pandemic. J Emerg Med. 2021;60:292–298. doi: 10.1016/j.jemermed.2020.11.005 71. Donoghue AJ, Donoghue AJ, Henretig FM, Donoghue AJ, Kou M, Good GL, Kochman A, Kou M, Stacks H, Eiger C, et al. Impact of personal protective equipment on pediatric cardiopulmonary resuscitation performance: a controlled trial. Pediatr Emerg Care. 2020;36:267–273. doi: 10.1097/PEC.0000000000002109 72. Shin DM, Kim SY, Shin SD, Kim CH, Kim TH, Kim K, Kim JH, Hong EJ. Effect of wearing personal protective equipment on cardiopulmonary resuscitation: focusing on 119 emergency medical technicians. Korean J Emerg Med Service. 2015;19:19–32. 73. Cavallin F, Lupi F, Bua B, Bellutti M, Staffler A, Trevisanuto D. Impact of personal protective equipment on neonatal resuscitation procedures: a randomised, cross-over, simulation study. Arch Dis Child Fetal Neonatal Ed. 2022;107:211–215. doi: 10.1136/archdischild-2021-322216 74. Watson L, Sault W, Gwyn R, Verbeek PR. The “delay effect” of donning a gown during cardiopulmonary resuscitation in a simulation model. CJEM. 2008;10:333–338. doi: 10.1017/s1481803500010332 75. Deleted in proof. 76. Jo CH, Cho GC, Ahn JH, Park YS, Lee CH. Rescuer-limited cardiopulmonary resuscitation as an alternative to 2-min switched CPR in the setting of inhospital cardiac arrest: a randomised cross-over study. Emerg Med J. 2015;32:539. doi: 10.1136/emermed-2013-203477 77. Kollander L, Folke F, Bray J; International Liaison Committee on Resuscitation Basic Life Support Task Force. Drone AEDs Task Force synthesis of a scoping Review. Accessed January 15, 2023. https://costr.ilcor.org/document/drone-aeds-bls-tf-scr 78. Bauer J, Moormann D, Strametz R, Groneberg DA. Development of unmanned aerial vehicle (UAV) networks delivering early defibrillation for out-of-hospital cardiac arrests (OHCA) in areas lacking timely access to emergency medical services (EMS) in Germany: a comparative economic study. BMJ Open. 2021;11:e043791. doi: 10.1136/bmjopen-2020-043791 79. Bogle B, Rosamond WD, Snyder KT, Zègre-Hemsey JK. The case for droneassisted emergency response to cardiac arrest. N C Med J. 2019;80:204– 212. doi: 10.18043/ncm.80.4.204 80. Boutilier JJ, Brooks SC, Janmohamed A, Byers A, Buick JE, Zhan C, Schoellig AP, Cheskes S, Morrison LJ, Chan TCY. Optimizing a drone network to deliver automated external defibrillators. Circulation. 2017;135:2454–2465. doi: 10.1161/CIRCULATIONAHA.116.026318 81. Choi DS, Hong KJ, Shin SD, Lee CG, Kim TH, Cho Y, Song KJ, Ro YS, Park JH, Kim KH. Effect of topography and weather on delivery of automatic electrical defibrillator by drone for out-of-hospital cardiac arrest. Sci Rep. 2021;11:24195. doi: 10.1038/s41598-021-03648-3 82. Chu J, Leung KHB, Snobelen P, Nevils G, Drennan IR, Cheskes S, Chan TCY. Machine learning-based dispatch of drone-delivered defibrillators for out-of-hospital cardiac arrest. Resuscitation. 2021;162:120–127. doi: 10.1016/j.resuscitation.2021.02.028 83. Claesson A, Fredman D, Svensson L, Ringh M, Hollenberg J, Nordberg P, Rosenqvist M, Djarv T, Österberg S, Lennartsson J, et al. Unmanned aerial vehicles (drones) in out-of-hospital-cardiac-arrest. Scand J Trauma Resusc Emerg Med. 2016;24:124. doi: 10.1186/s13049-016-0313-5 84. Derkenne C, Jost D, L’Espinay AMD, Corpet P, Frattini B, Hong V, Lemoine F, Jouffroy R, Roquet F, Marijon E, et al. Automatic external defibrillator provided by unmanned aerial vehicle (drone) in Greater Paris: a real world-based simulation. Resuscitation. 2021;162:259–265. doi: 10.1016/j.resuscitation.2021.03.012 85. Lancaster G, Herrmann J. Simulating cardiac arrest events to evaluate novel emergency response systems. IISE Trans Healthc Syst Eng. 2021;11:38–50. doi: 10.1080/24725579.2020.1836090 86. Lancaster G, Herrmann JW. Computer simulation of the effectiveness of novel cardiac arrest response systems. Resusc Plus. 2021;7:100153. doi: 10.1016/j.resplu.2021.100153 87. Leung KHB, Grunau B, Al Assil R, Heidet M, Liang LD, Deakin J, Christenson J, Cheskes S, Chan TCY. Incremental gains in response time with varying base location types for drone-delivered automated external defibrillators. Resuscitation. 2022;174:24–30. doi: 10.1016/j.resuscitation.2022.03.013 88. Mackle C, Bond R, Torney H, McBride R, McLaughlin J, Finlay D, Biglarbeigi P, Brisk R, Harvey A, McEneaney D. A data-driven simulator for the strategic positioning of aerial ambulance drones reaching out-of-hospital cardiac arrests: a genetic algorithmic approach. IEEE J Transl Eng Health Med. 2020;8:1900410. doi: 10.1109/JTEHM.2020.2987008 89. Pulver A, Wei R. Optimizing the spatial location of medical drones. Appl Geogr. 2018;90:9–16. doi: 10.1016/j.apgeog.2017.11.009 90. Pulver A, Wei R, Mann C. Locating AED enabled medical drones to enhance cardiac arrest response times. Prehosp Emerg Care. 2016;20:378– 389. doi: 10.3109/10903127.2015.1115932 91. Roper JWA, Fischer K, Baumgarten MC, Thies KC, Hahnenkamp K, Flessa S. Can drones save lives and money? An economic evaluation of airborne delivery of automated external defibrillators. Eur J Health Econ. 2023;24:1141–1150. doi: 10.1007/s10198-022-01531-0 92. Schierbeck S, Nord A, Svensson L, Rawshani A, Hollenberg J, Ringh M, Forsberg S, Nordberg P, Hilding F, Claesson A. National coverage of outof-hospital cardiac arrests using automated external defibrillator-equipped drones: a geographical information system analysis. Resuscitation. 2021;163:136–145. doi: 10.1016/j.resuscitation.2021.02.040 93. Wankmüller C, Truden C, Korzen C, Hungerländer P, Kolesnik E, Reiner G. Optimal allocation of defibrillator drones in mountainous regions. OR Spectrum. 2020;42:785–814. doi: 10.1007/s00291-020-00575-z 94. Baumgarten MC, Röper J, Hahnenkamp K, Thies K-C. Drones delivering automated external defibrillators: integrating unmanned aerial systems into the chain of survival: a simulation study in rural Germany. Resuscitation. 2022;172:139–145. doi: 10.1016/j.resuscitation.2021.12.025 95. Cheskes S, McLeod SL, Nolan M, Snobelen P, Vaillancourt C, Brooks SC, Dainty KN, Chan TCY, Drennan IR. Improving access to automated external defibrillators in rural and remote settings: a drone delivery feasibility study. J Am Heart Association. 2020;9:e016687. doi: 10.1161/JAHA.120.016687 96. Claesson A, Bäckman A, Ringh M, Svensson L, Nordberg P, Djärv T, Hollenberg J. Time to delivery of an automated external defibrillator using a drone for simulated out-of-hospital cardiac arrests vs emergency medical services. JAMA. 2017;317:2332. doi: 10.1001/jama.2017.3957 97. Kim H-J, Kim J-H, Park D. Comparing audioand video-delivered instructions in dispatcher-assisted cardiopulmonary resuscitation with drone-delivered automatic external defibrillator: a mixed methods simulation study. PeerJ. 2021;9:e11761. doi: 10.7717/peerj.11761 98. Rees N, Howitt J, Breyley N, Geoghegan P, Powel C. A simulation study of drone delivery of automated external defibrillator (AED) in out of hospital cardiac arrest (OHCA) in the UK. PLoS One. 2021;16:e0259555. doi: 10.1371/journal.pone.0259555 99. Rosamond WD, Johnson AM, Bogle BM, Arnold E, Cunningham CJ, Picinich M, Williams BM, Zegre-Hemsey JK. Drone delivery of an automated external defibrillator. N Engl J Med. 2020;383:1186–1188. doi: 10.1056/NEJMc1915956 100. Sanfridsson J, Sparrevik J, Hollenberg J, Nordberg P, Djärv T, Ringh M, Svensson L, Forsberg S, Nord A, Andersson-Hagiwara M, et al. Drone delivery of an automated external defibrillator: a mixed method simulation study of bystander experience. Scand J Trauma Resusc Emerg Med. 2019;27:40. doi: 10.1186/s13049-019-0622-6 101. Sedig K, Seaton MB, Drennan IR, Cheskes S, Dainty KN. “Drones are a great idea! What is an AED?” Novel insights from a qualitative study on public perception of using drones to deliver Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e269 automatic external defibrillators. Resusc Plus. 2020;4:100033. doi: 10.1016/j.resplu.2020.100033 102. Zègre-Hemsey JK, Grewe ME, Johnson AM, Arnold E, Cunningham CJ, Bogle BM, Rosamond WD. Delivery of automated external defibrillators via drones in simulated cardiac arrest: users’ experiences and the human-drone interaction. Resuscitation. 2020;157:83–88. doi: 10.1016/j.resuscitation.2020.10.006 103. Schierbeck S, Hollenberg J, Nord A, Svensson L, Nordberg P, Ringh M, Forsberg S, Lundgren P, Axelsson C, Claesson A. Automated external defibrillators delivered by drones to patients with suspected out-of-hospital cardiac arrest. Eur Heart J. 2022;43:1478–1487. doi: 10.1093/eurheartj/ehab498 104. Schierbeck S, Svensson L, Claesson A. Use of a drone-delivered automated external defibrillator in an out-of-hospital cardiac arrest. N Engl J Med. 2022;386:1953–1954. doi: 10.1056/NEJMc2200833 105. Holmberg MJ, Geri G, Wiberg S, Guerguerian AM, Donnino MW, Nolan JP, Deakin CD, Andersen LW; International Liaison Committee on Resuscitation’s (ILCOR) Advanced Life Support and Pediatric Task Force. Extracorporeal cardiopulmonary resuscitation for cardiac arrest: a systematic review. Resuscitation. 2018;131:91–100. doi: 10.1016/j.resuscitation.2018.07.029 106. Holmberg MJ, Granfeldt A, Guerguerian AM, Sandroni C, Hsu CH, Gardner RM, Lind PC, Eggertsen MA, Johannsen CM, Andersen LW. Extracorporeal cardiopulmonary resuscitation for cardiac arrest: an updated systematic review. Resuscitation. 2023;182:109665. doi: 10.1016/j.resuscitation.2022.12.003 107. ILCOR Advanced Life Support Adult Task Force. Extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest: ALS TFSR. Updated January 19, 2023. Accessed February 22, 2023. https://costr.ilcor.org/ document/extracorporeal-cardiopulmonary-resuscitation-ecpr-for-cardiac-arrest-als-tfsr 108. Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, Collins G, Zhang L, Kalra R, Kosmopoulos M, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, openlabel, randomised controlled trial. Lancet. 2020;396:1807–1816. doi: 10.1016/S0140-6736(20)32338-2 109. Hsu CH, Meurer WJ, Domeier R, Fowler J, Whitmore SP, Bassin BS, Gunnerson KJ, Haft JW, Lynch WR, Nallamothu BK, et al. Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest (EROCA): results of a randomized feasibility trial of expedited out-of-hospital transport. Ann Emerg Med. 2021;78:92–101. doi: 10.1016/j.annemergmed.2020.11.011 110. Belohlavek J, Rob D, Smalcova J. Effect of intra-arrest transport and extracorporeal cardiopulmonary resuscitation on functional neurologic outcome in refractory out-of-hospital cardiac arrest: reply. JAMA. 2022;327:2357. doi: 10.1001/jama.2022.6548 111. Deakin CD, Morley P, Soar J, Drennan IR. Double (dual) sequential defibrillation for refractory ventricular fibrillation cardiac arrest: a systematic review. Resuscitation. 2020;155:24–31. doi: 10.1016/j.resuscitation.2020.06.008 112. Ohshimo S, Drennan I, Deakin CD, Soar J, Berg KM; International Liaison Committee on Resuscitation Advanced Life Support Task Force. Double sequential defibrillation strategy for cardiac arrest with refractory shockable rhythm: ALS TFSR. Updated December 5, 2022. Accessed February 22, 2023. https://costr.ilcor.org/document/ header-double-sequence-defibrillation-task-force-systematic-review-costr 113. Cheskes S, Dorian P, Feldman M, McLeod S, Scales DC, Pinto R, Turner L, Morrison LJ, Drennan IR, Verbeek PR. Double sequential external defibrillation for refractory ventricular fibrillation: the DOSE VF pilot randomized controlled trial. Resuscitation. 2020;150:178–184. doi: 10.1016/j.resuscitation.2020.02.010 114. Cheskes S, Verbeek PR, Drennan IR, McLeod SL, Turner L, Pinto R, Feldman M, Davis M, Vaillancourt C, Morrison LJ, et al. Defibrillation strategies for refractory ventricular fibrillation. N Engl J Med. 2022;387:1947– 1956. doi: 10.1056/NEJMoa2207304 115. de Latorre F, Nolan J, Robertson C, Chamberlain D, Baskett P; European Resuscitation Council. European Resuscitation Council guidelines 2000 for adult advanced life support. a statement from the Advanced Life Support Working Group and approved by the Executive Committee of the European Resuscitation Council. Resuscitation. 2001;48:211–221. doi: 10.1016/s0300-9572(00)00379-8 116. Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, et al; Advanced Life Support Chapter Collaborators. Part 8: advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122(suppl 2):S345–S421. doi: 10.1161/CIRCULATIONAHA.110.971051 117. Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Maerkedahl R, Mortensen LR, Nyboe R, et al. Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest: a randomized clinical trial. JAMA. 2021;326:2268–2276. doi: 10.1001/jama.2021.20929 118. Hsu CH, Couper K, Nix T, Drennan I, Reynolds J, Kleinman M, Berg KM, Advanced Life S; Paediatric Life Support Task Forces at the International Liaison Committee on Resuscitation. Calcium during cardiac arrest: a systematic review. Resusc Plus. 2023;14:100379. doi: 10.1016/j.resplu.2023.100379 119. Hsu CH, Couper K, Nix T, Drennan I, Reynolds J, Kleinman M, Berg KM; Advanced Life Support and Paediatric Life Support Task Forces at the International Liaison Committee on Resuscitation. Calcium during cardiac arrest: ALS TFSR. Updated December 6, 2022. Accessed February 22, 2023. https://costr.ilcor.org/document/calcium-during-cardiac-arrest-als-tfsr 120. Stueven HA, Thompson B, Aprahamian C, Tonsfeldt DJ, Kastenson EH. The effectiveness of calcium chloride in refractory electromechanical dissociation. Ann Emerg Med. 1985;14:626–629. doi: 10.1016/s0196-0644(85)80874-x 121. Stueven HA, Thompson B, Aprahamian C, Tonsfeldt DJ, Kastenson EH. Lack of effectiveness of calcium chloride in refractory asystole. Ann Emerg Med. 1985;14:630–632. doi: 10.1016/s0196-0644(85)80875-1 122. Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Maerkedahl R, Mortensen LR, Nyboe R, et al. Effect of calcium vs. placebo on long-term outcomes in patients with out-of-hospital cardiac arrest. Resuscitation. 2022;179:21–24. doi: 10.1016/j.resuscitation.2022.07.034 123. Berg KM, Soar J, Andersen LW, Bottiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, et al; Adult Advanced Life Support Collaborators. Adult advanced life support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A80– A119. doi: 10.1016/j.resuscitation.2020.09.012 124. Berg KM, Soar J, Andersen LW, Bottiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, et al; Adult Advanced Life Support Collaborators. Adult advanced life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142:S92–S139. doi: 10.1161/CIR.0000000000000893 125. Sandroni C, D’Arrigo S, Cacciola S, Hoedemaekers CWE, Westhall E, Kamps MJA, Taccone FS, Poole D, Meijer FJA, Antonelli M, et al. Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med. 2022;48:389–413. doi: 10.1007/s00134-022-06618-z 126. Steinberg A, Callaway CW, Arnold RM, Cronberg T, Naito H, Dadon K, Chae MK, Elmer J. Prognostication after cardiac arrest: results of an international, multi-professional survey. Resuscitation. 2019;138:190–197. doi: 10.1016/j.resuscitation.2019.03.016 127. Skrifvars M, Sandroni C, Hirsch K; ILCOR Advanced Life Support Task Force. Use of the Glasgow Coma Scale motor score for the prediction of good outcome after cardiac arrest: ALS TFSR. Updated February 1, 2023. Accessed February 22, 2023. https://costr.ilcor.org/document/ use-of-the-glasgow-coma-scale-motor-score-for-the-prediction-of-goodoutcome-after-cardiac-arrest-als-tfsr 128. Moseby-Knappe M, Westhall E, Backman S, Mattsson-Carlgren N, Dragancea I, Lybeck A, Friberg H, Stammet P, Lilja G, Horn J, et al. Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest. Intensive Care Med. 2020;46:1852–1862. doi: 10.1007/s00134-020-06080-9 129. Hifumi T, Kuroda Y, Kawakita K, Sawano H, Tahara Y, Hase M, Nishioka K, Shirai S, Hazui H, Arimoto H, et al; J-PULSE-Hypo Investigators. Effect of admission Glasgow Coma Scale motor score on neurological outcome in out-of-hospital cardiac arrest patients receiving therapeutic hypothermia. Circ J. 2015;79:2201–2208. doi: 10.1253/circj.CJ-15-0308 130. Sandroni C, Skrifvars M, Humaloja J, Hirsch K; ILCOR Advanced Life Support Task Force. Imaging for prediction of good neurological outcome: ALS TFSR. Updated February 1, 2023. Accessed February 22, 2023. https://costr.ilcor.org/document/ imaging-for-prediction-of-good-neurological-outcome-als-tfsr Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e270 131. Lee KS, Lee SE, Choi JY, Gho YR, Chae MK, Park EJ, Choi MH, Hong JM. Useful computed tomography score for estimation of early neurologic outcome in post-cardiac arrest patients with therapeutic hypothermia. Circ J. 2017;81:1628–1635. doi: 10.1253/circj.CJ-16-1327 132. Jang J, Oh SH, Nam Y, Lee K, Choi HS, Jung SL, Ahn KJ, Park KN, Kim BS. Prognostic value of phase information of 2D T2*-weighted gradient echo brain imaging in cardiac arrest survivors: a preliminary study. Resuscitation. 2019;140:142–149. doi: 10.1016/j.resuscitation.2019.05.026 133. Oh SH, Park KN, Choi SP, Oh JS, Kim HJ, Youn CS, Kim SH, Chang K, Kim SH. Beyond dichotomy: patterns and amplitudes of SSEPs and neurological outcomes after cardiac arrest. Crit Care. 2019;23:224. doi: 10.1186/s13054-019-2510-x 134. Park JS, In YN, You YH, Min JH, Ahn HJ, Yoo IS, Kim SW, Lee JW, Ryu S, Jeong WJ, et al. Ultra-early neurologic outcome prediction of out-ofhospital cardiac arrest survivors using combined diffusion-weighted imaging findings and quantitative analysis of apparent diffusion coefficient. Resuscitation. 2020;148:39–48. doi: 10.1016/j.resuscitation.2019.12.021 135. Mlynash M, Campbell DM, Leproust EM, Fischbein NJ, Bammer R, Eyngorn I, Hsia AW, Moseley M, Wijman CA. Temporal and spatial profile of brain diffusion-weighted MRI after cardiac arrest. Stroke. 2010;41:1665–1672. doi: 10.1161/STROKEAHA.110.582452 136. Wouters A, Scheldeman L, Plessers S, Peeters R, Cappelle S, Demaerel P, Van Paesschen W, Ferdinande B, Dupont M, Dens J, et al. Added value of quantitative apparent diffusion coefficient values for neuroprognostication after cardiac arrest. Neurology. 2021;96:e2611–e2618. doi: 10.1212/WNL.0000000000011991 137. Skrifvars M, Humaloja J, Sandroni C, Hirsch K; ILCOR Advanced Life Support Task Force. Use of brain injury biomarkers for the prediction of good outcome after cardiac arrest: ALS TFSR. Accessed February 22, 2023. https://costr.ilcor.org/document/use-of-brain-injury-biomarkersfor-the-prediction-of-good-outcome-after-cardiac-arrest-als-tfsr 138. Zellner T, Gartner R, Schopohl J, Angstwurm M. NSE and S-100B are not sufficiently predictive of neurologic outcome after therapeutic hypothermia for cardiac arrest. Resuscitation. 2013;84:1382–1386. doi: 10.1016/j.resuscitation.2013.03.021 139. Moseby-Knappe M, Mattsson-Carlgren N, Stammet P, Backman S, Blennow K, Dankiewicz J, Friberg H, Hassager C, Horn J, Kjaergaard J, et al. Serum markers of brain injury can predict good neurological outcome after out-of-hospital cardiac arrest. Intensive Care Med. 2021;47:984–994. doi: 10.1007/s00134-021-06481-4 140. Streitberger KJ, Leithner C, Wattenberg M, Tonner PH, Hasslacher J, Joannidis M, Pellis T, Di Luca E, Fodisch M, Krannich A, et al. Neuronspecific enolase predicts poor outcome after cardiac arrest and targeted temperature management: a multicenter study on 1,053 patients. Crit Care Med. 2017;45:1145–1151. doi: 10.1097/CCM.0000000000002335 141. Wihersaari L, Ashton NJ, Reinikainen M, Jakkula P, Pettila V, Hastbacka J, Tiainen M, Loisa P, Friberg H, Cronberg T, et al; COMACARE Study Group. Neurofilament light as an outcome predictor after cardiac arrest: a post hoc analysis of the COMACARE trial. Intensive Care Med. 2021;47:39–48. doi: 10.1007/s00134-020-06218-9 142. Wihersaari L, Reinikainen M, Furlan R, Mandelli A, Vaahersalo J, Kurola J, Tiainen M, Pettila V, Bendel S, Varpula T, et al. Neurofilament light compared to neuron-specific enolase as a predictor of unfavourable outcome after out-of-hospital cardiac arrest. Resuscitation. 2022;174:1–8. doi: 10.1016/j.resuscitation.2022.02.024 143. Humaloja J, Lahde M, Ashton NJ, Reinikainen M, Hastbacka J, Jakkula P, Friberg H, Cronberg T, Pettila V, Blennow K, et al; COMACARE Study Groups. GFAp and tau protein as predictors of neurological outcome after out-of-hospital cardiac arrest: a post hoc analysis of the COMACARE trial. Resuscitation. 2022;170:141–149. doi: 10.1016/j.resuscitation.2021.11.033 144. Hirsch K, Sandroni C, Skrifvars M, Humaloja J; ILCOR Advanced Life Support Task Force. EEG for prediction of good neurological outcome: ALS TFSR. Updated December 22, 2022. Accessed February 22, 2023. https://costr.ilcor.org/document/ eeg-for-prediction-of-good-neurological-outcome-als-tfsr 145. Admiraal MM, van Rootselaar AF, Hofmeijer J, Hoedemaekers CWE, van Kaam CR, Keijzer HM, van Putten M, Schultz MJ, Horn J. Electroencephalographic reactivity as predictor of neurological outcome in postanoxic coma: a multicenter prospective cohort study. Ann Neurol. 2019;86:17–27. doi: 10.1002/ana.25507 146. Backman S, Cronberg T, Friberg H, Ullen S, Horn J, Kjaergaard J, Hassager C, Wanscher M, Nielsen N, Westhall E. Highly malignant routine EEG predicts poor prognosis after cardiac arrest in the Target Temperature Management trial. Resuscitation. 2018;131:24–28. doi: 10.1016/j.resuscitation.2018.07.024 147. Beretta S, Coppo A, Bianchi E, Zanchi C, Carone D, Stabile A, Padovano G, Sulmina E, Grassi A, Bogliun G, et al. Neurological outcome of postanoxic refractory status epilepticus after aggressive treatment. Epilepsy Behav. 2019;101:106374. doi: 10.1016/j.yebeh.2019.06.018 148. Carrai R, Grippo A, Scarpino M, Spalletti M, Cossu C, Lanzo G, Peris A, Cianchi G, Batacchi S, Valente S, et al. Time-dependent and independent neurophysiological indicators of prognosis in post-anoxic coma subjects treated by therapeutic hypothermia. Minerva Anestesiol. 2016;82:940–949. 149. Carrai R, Spalletti M, Scarpino M, Lolli F, Lanzo G, Cossu C, Bonizzoli M, Socci F, Lazzeri C, Amantini A, et al. Are neurophysiologic tests reliable, ultra-early prognostic indices after cardiac arrest? Neurophysiol Clin. 2021;51:133–144. doi: 10.1016/j.neucli.2021.01.005 150. Scarpino M, Lolli F, Lanzo G, Carrai R, Spalletti M, Valzania F, Lombardi M, Audenino D, Contardi S, Celani MG, et al; ProNeCA Study Group. SSEP amplitude accurately predicts both good and poor neurological outcome early after cardiac arrest; a post-hoc analysis of the ProNeCA multicentre study. Resuscitation. 2021;163:162–171. doi: 10.1016/j.resuscitation.2021.03.028 151. Duez CHV, Johnsen B, Ebbesen MQ, Kvaloy MB, Grejs AM, Jeppesen AN, Soreide E, Nielsen JF, Kirkegaard H. Post resuscitation prognostication by EEG in 24 vs 48 h of targeted temperature management. Resuscitation. 2019;135:145–152. doi: 10.1016/j.resuscitation.2018.10.035 152. Hofmeijer J, Beernink TM, Bosch FH, Beishuizen A, Tjepkema-Cloostermans MC, van Putten MJ. Early EEG contributes to multimodal outcome prediction of postanoxic coma. Neurology. 2015;85:137–143. doi: 10.1212/WNL.0000000000001742 153. Sondag L, Ruijter BJ, Tjepkema-Cloostermans MC, Beishuizen A, Bosch FH, van Til JA, van Putten M, Hofmeijer J. Early EEG for outcome prediction of postanoxic coma: prospective cohort study with cost-minimization analysis. Crit Care. 2017;21:111. doi: 10.1186/s13054-017-1693-2 154. Rossetti AO, Tovar Quiroga DF, Juan E, Novy J, White RD, Ben-Hamouda N, Britton JW, Oddo M, Rabinstein AA. Electroencephalography predicts poor and good outcomes after cardiac arrest: a two-center study. Crit Care Med. 2017;45:e674–e682. doi: 10.1097/CCM.0000000000002337 155. Westhall E, Rossetti AO, van Rootselaar AF, Wesenberg Kjaer T, Horn J, Ullen S, Friberg H, Nielsen N, Rosen I, Aneman A, et al; TTM-Trial Investigators. Standardized EEG interpretation accurately predicts prognosis after cardiac arrest. Neurology. 2016;86:1482–1490. doi: 10.1212/WNL.0000000000002462 156. Sivaraju A, Gilmore EJ, Wira CR, Stevens A, Rampal N, Moeller JJ, Greer DM, Hirsch LJ, Gaspard N. Prognostication of post-cardiac arrest coma: early clinical and electroencephalographic predictors of outcome. Intensive Care Med. 2015;41:1264–1272. doi: 10.1007/s00134-015-3834-x 157. Alvarez V, Reinsberger C, Scirica B, O’Brien MH, Avery KR, Henderson G, Lee JW. Continuous electrodermal activity as a potential novel neurophysiological biomarker of prognosis after cardiac arrest: a pilot study. Resuscitation. 2015;93:128–135. doi: 10.1016/j.resuscitation.2015.06.006 158. Lamartine Monteiro M, Taccone FS, Depondt C, Lamanna I, Gaspard N, Ligot N, Mavroudakis N, Naeije G, Vincent JL, Legros B. The prognostic value of 48-h continuous EEG during therapeutic hypothermia after cardiac arrest. Neurocrit Care. 2016;24:153–162. doi: 10.1007/s12028-015-0215-9 159. Leao RN, Avila P, Cavaco R, Germano N, Bento L. Therapeutic hypothermia after cardiac arrest: outcome predictors. Rev Bras Ter Intensiva. 2015;27:322–332. doi: 10.5935/0103-507X.20150056 160. Wennervirta JE, Ermes MJ, Tiainen SM, Salmi TK, Hynninen MS, Sarkela MO, Hynynen MJ, Stenman UH, Viertio-Oja HE, Saastamoinen KP, et al. Hypothermia-treated cardiac arrest patients with good neurological outcome differ early in quantitative variables of EEG suppression and epileptiform activity. Crit Care Med. 2009;37:2427–2435. doi: 10.1097/CCM.0b013e3181a0ff84 161. Oh SH, Park KN, Kim YM, Kim HJ, Youn CS, Kim SH, Choi SP, Kim SC, Shon YM. The prognostic value of continuous amplitude-integrated electroencephalogram applied immediately after return of spontaneous circulation in therapeutic hypothermia-treated cardiac arrest patients. Resuscitation. 2013;84:200–205. doi: 10.1016/j.resuscitation.2012.09.031 162. Rundgren M, Westhall E, Cronberg T, Rosen I, Friberg H. Continuous amplitude-integrated electroencephalogram predicts outcome in hypothermiatreated cardiac arrest patients. Crit Care Med. 2010;38:1838–1844. doi: 10.1097/CCM.0b013e3181eaa1e7 163. Eertmans W, Genbrugge C, Haesen J, Drieskens C, Demeestere J, Vander Laenen M, Boer W, Mesotten D, Dens J, Ernon L, et al. The Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e271 prognostic value of simplified EEG in out-of-hospital cardiac arrest patients. Neurocrit Care. 2019;30:139–148. doi: 10.1007/s12028-018-0587-8 164. Tjepkema-Cloostermans MC, van Meulen FB, Meinsma G, van Putten MJ. A Cerebral Recovery Index (CRI) for early prognosis in patients after cardiac arrest. Crit Care. 2013;17:R252. doi: 10.1186/cc13078 165. Park JH, Oh JH, Choi SP, Wee JH. Neurologic outcome after out-of-hospital cardiac arrest could be predicted with the help of bispectral-index during early targeted temperature management. Scand J Trauma Resusc Emerg Med. 2018;26:59. doi: 10.1186/s13049-018-0529-7 166. Seder DB, Fraser GL, Robbins T, Libby L, Riker RR. The bispectral index and suppression ratio are very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest. Intensive Care Med. 2010;36:281–288. doi: 10.1007/s00134-009-1691-1 167. Leary M, Fried DA, Gaieski DF, Merchant RM, Fuchs BD, Kolansky DM, Edelson DP, Abella BS. Neurologic prognostication and bispectral index monitoring after resuscitation from cardiac arrest. Resuscitation. 2010;81:1133–1137. doi: 10.1016/j.resuscitation.2010.04.021 168. ILCOR Advanced Life Support Adult Task Force. Short-latency somatosensory evoked potentials (SSEPs) for prediction of good neurological outcome: ALS TFSR. Updated February 1, 2023. Accessed February 22, 2023. https://costr.ilcor.org/document/short-latency-somatosensoryevoked-potentials-sseps-for-prediction-of-good-neurological-outcomeals-tfsr 169. Endisch C, Storm C, Ploner CJ, Leithner C. Amplitudes of SSEP and outcome in cardiac arrest survivors: a prospective cohort study. Neurology. 2015;85:1752–1760. doi: 10.1212/WNL.0000000000002123 170. Benghanem S, Nguyen LS, Gavaret M, Mira JP, Pene F, Charpentier J, Marchi A, Cariou A. SSEP N20 and P25 amplitudes predict poor and good neurologic outcomes after cardiac arrest. Ann Intensive Care. 2022;12:25. doi: 10.1186/s13613-022-00999-6 171. Glimmerveen AB, Keijzer HM, Ruijter BJ, Tjepkema-Cloostermans MC, van Putten M, Hofmeijer J. Relevance of somatosensory evoked potential amplitude after cardiac arrest. Front Neurol. 2020;11:335. doi: 10.3389/fneur.2020.00335 172. Deleted in proof. 173. Deleted in proof. 174. Holmberg MJ, Granfeldt A, Guerguerian A-M, Sandroni C, Hsu CH, Gardner RM, Lind PC, Eggertsen MA, Johannsen CM, Andersen LW. Extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest in pediatrics: PLS TFSR. Accessed March 7, 2023. https://costr.ilcor.org/document/ extracorporeal-cardiopulmonary-resuscitation-ecpr-for-cardiac-arrest-inpediatrics-pls-tfsr 175. Moler FW, Silverstein FS, Holubkov R, Slomine BS, Christensen JR, Nadkarni VM, Meert KL, Browning B, Pemberton VL, Page K, et al. Therapeutic hypothermia after in-hospital cardiac arrest in children. N Engl J Med. 2017;376:318–329. doi: 10.1056/NEJMoa1610493 176. Meert K, Telford R, Holubkov R, Slomine BS, Christensen JR, Berger J, Ofori-Amanfo G, Newth CJL, Dean JM, Moler FW. Paediatric in-hospital cardiac arrest: factors associated with survival and neurobehavioural outcome one year later. Resuscitation. 2018;124:96–105. doi: 10.1016/j.resuscitation.2018.01.013 177. Meert KL, Guerguerian AM, Barbaro R, Slomine BS, Christensen JR, Berger J, Topjian A, Bembea M, Tabbutt S, Fink EL, et al. Extracorporeal cardiopulmonary resuscitation: one-year survival and neurobehavioral outcome among infants and children with in-hospital cardiac arrest. Crit Care Med. 2019;47:393–402. doi: 10.1097/CCM.0000000000003545 178. Ichord R, Silverstein FS, Slomine BS, Telford R, Christensen J, Holubkov R, Dean JM, Moler FW; THAPCA Trial Group. Neurologic outcomes in pediatric cardiac arrest survivors enrolled in the THAPCA trials. Neurology. 2018;91:e123–e131. doi: 10.1212/wnl.0000000000005773 179. Mullen EM. Mullen Scales of Early Learning. American Guidance; 1995. 180. Wechsler D. Wechsler Abbreviated Scale of Intelligence: Psychological Corp; 1999. 181. Hamzah M, Othman HF, Almasri M, Al-Subu A, Lutfi R. Survival outcomes of in-hospital cardiac arrest in pediatric patients in the USA. Eur J Pediatr. 2021;180:2513–2520. doi: 10.1007/s00431-021-04082-3 182. Taeb M, Levin AB, Spaeder MC, Schwartz JM. Comparison of pediatric cardiopulmonary resuscitation quality in classic cardiopulmonary resuscitation and extracorporeal cardiopulmonary resuscitation events using video review. Pediatr Crit Care Med. 2018;19:831–838. doi: 10.1097/pcc.0000000000001644 183. Pollack MM, Holubkov R, Funai T, Clark A, Moler F, Shanley T, Meert K, Newth CJL, Carcillo J, Berger JT, et al. Relationship between the Functional Status Scale and the Pediatric Overall Performance Category and Pediatric Cerebral Performance Category Scales. JAMA Pediatrics. 2014;168:671. doi: 10.1001/jamapediatrics.2013.5316 184. Topjian AA, Scholefield BR, Pinto NP, Fink EL, Buysse CMP, Haywood K, Maconochie I, Nadkarni VM, de Caen A, Escalante-Kanashiro R, et al. P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in children: an advisory statement from the International Liaison Committee on Resuscitation. Circulation. 2020;142:e246–e261. doi: 10.1161/cir.0000000000000911 185. Scholefield BR, Tijssen J, Ganesan SL, Kool M, Topjian A, Couto TB, Guerguerian A-M; International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Clinical examination for the prediction of survival with good neurological outcome after return of circulation following pediatric cardiac arrest: PLS TFSR. Accessed March 7, 2023. https:// costr.ilcor.org/document/clinical-examination-for-the-prediction-of-survival-with-good-neurological-outcome-after-return-of-circulation-followingpediatric-cardiac-arrest-pls-tfsr-1 186. Abend NS, Topjian AA, Kessler SK, Gutierrez-Colina AM, Berg RA, Nadkarni V, Dlugos DJ, Clancy RR, Ichord RN. Outcome prediction by motor and pupillary responses in children treated with therapeutic hypothermia after cardiac arrest. Pediatric Crit Care Med. 2012;13:32–38. doi: 10.1097/PCC.0b013e3182196a7b 187. Anton-Martin P, Moreira A, Kang P, Green ML. Outcomes of paediatric cardiac patients after 30 minutes of cardiopulmonary resuscitation prior to extracorporeal support. Cardiol Young. 2020;30:607–616. doi: 10.1017/S1047951120000591 188. Brooks GA, Park JT. Clinical and electroencephalographic correlates in pediatric cardiac arrest: experience at a tertiary care center. Neuropediatrics. 2018;49:324–329. doi: 10.1055/s-0038-1657757 189. Ducharme-Crevier L, Press CA, Kurz JE, Mills MG, Goldstein JL, Wainwright MS. Early presence of sleep spindles on electroencephalography is associated with good outcome after pediatric cardiac arrest. Pediatr Crit Care Med. 2017;18:452–460. doi: 10.1097/PCC.0000000000001137 190. Fink EL, Berger RP, Clark RSB, Watson RS, Angus DC, Richichi R, Panigrahy A, Callaway CW, Bell MJ, Kochanek PM. Serum biomarkers of brain injury to classify outcome after pediatric cardiac arrest. Crit Care Med. 2014;42:664–674. doi: 10.1097/01.ccm.0000435668.53188.80 191. Lin JJ, Hsu MH, Hsia SH, Lin YJ, Wang HS, Kuo HC, Chiang MC, Chan OW, Lee EP, Lin KL; iCNS Group. Epileptiform discharge and electrographic seizures during the hypothermia phase as predictors of rewarming seizures in children after resuscitation. J Clin Med. 2020;9:534. doi: 10.3390/jcm9072151 192. Topjian AA, Zhang B, Xiao R, Fung FW, Berg RA, Graham K, Abend NS. Multimodal monitoring including early EEG improves stratification of brain injury severity after pediatric cardiac arrest. Resuscitation. 2021;167:282– 288. doi: 10.1016/j.resuscitation.2021.06.020 193. Nishisaki A, Sullivan J 3rd, Steger B, Bayer CR, Dlugos D, Lin R, Ichord R, Helfaer MA, Nadkarni V. Retrospective analysis of the prognostic value of electroencephalography patterns obtained in pediatric in-hospital cardiac arrest survivors during three years. Pediatr Crit Care Med. 2007;8:10–17. doi: 10.1097/01.pcc.0000256621.63135.4b 10.1097/01.pcc.0000256621.63135.4b 194. Lin YR, Wu HP, Chen WL, Wu KH, Teng TH, Yang MC, Chou CC, Chang CF, Li CJ. Predictors of survival and neurologic outcomes in children with traumatic out-of-hospital cardiac arrest during the early postresuscitative period. J Trauma Acute Care Surg. 2013;75:439–447. doi: 10.1097/TA.0b013e31829e2543 10.1097/TA.0b013e31829e2543 195. Scholefield BR, Tijssen J, Ganesan SL, Kool M, Topjian A, Couto TB, Guerguerian A-M; International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Blood biomarkers for the prediction of good neurological outcome after return of circulation following pediatric cardiac arrest: PLS TFSR. Accessed March 7, 2023. https://costr.ilcor.org/document/blood-biomarkers-for-the-prediction-of-good-neurological-outcomeafter-return-of-circulation-following-pediatric-cardiac-arrest-pls-tfsr 196. De La Llana RA, Le Marsney R, Gibbons K, Anderson B, Haisz E, Johnson K, Black A, Venugopal P, Mattke AC. Merging two hospitals: the effects on pediatric extracorporeal cardiopulmonary resuscitation outcomes. J Pediatr Intensive Care. 2021;10:202–209. doi: 10.1055/s-0040-1715853 197. Lopez-Herce J, del Castillo J, Matamoros M, Canadas S, Rodriguez-Calvo A, Cecchetti C, Rodriguez-Nunez A, Carrillo A; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI. Post return of spontaneous circulation factors associated with mortality in pediatric in-hospital cardiac arrest: a prospective multicenter multinational observational study. Crit Care. 2014;18:607. doi: 10.1186/s13054-014-0607-9 198. Meert K, Slomine BS, Silverstein FS, Christensen J, Ichord R, Telford R, Holubkov R, Dean JM, Moler FW. One-year cognitive and neurologic Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e272 outcomes in survivors of paediatric extracorporeal cardiopulmonary resuscitation. Resuscitation. 2019;139:299–307. doi: http://dx.doi.org/10.1016/j.resuscitation.2019.02.023 199. Moler FW, Silverstein FS, Holubkov R, Slomine BS, Christensen JR, Nadkarni VM, Meert KL, Clark AE, Browning B, Pemberton VL, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. 2015;372:1898–1908. doi: 10.1056/NEJMoa1411480 200. Fink EL, Kochanek PM, Panigrahy A, Beers SR, Berger RP, Bayir H, Pineda J, Newth C, Topjian AA, Press CA, et al. Association of bloodbased brain injury biomarker concentrations with outcomes after pediatric cardiac arrest. JAMA Netw Open. 2022;5:e2230518. doi: 10.1001/jamanetworkopen.2022.30518 201. Fink EL, Berger RP, Clark RSB, Watson RS, Angus DC, Panigrahy A, Richichi R, Callaway CW, Bell MJ, Mondello S, et al. Exploratory study of serum ubiquitin carboxyl-terminal esterase L1 and glial fibrillary acidic protein for outcome prognostication after pediatric cardiac arrest. Resuscitation. 2016;101:65–70. doi: 10.1016/j.resuscitation.2016.01.024 202. Kirschen MP, Yehya N, Graham K, Kilbaugh T, Berg RA, Topjian A, Diaz-Arrastia R. Circulating neurofilament light chain is associated with survival after pediatric cardiac arrest. Pediatr Crit Care Med. 2020;21:656–661. doi: 10.1097/pcc.0000000000002294 203. Bangshoj J, Liebetrau B, Wiberg S, Gjedsted J, Kjaergaard J, Hassager C, Wanscher M. The value of the biomarkers neuron-specific enolase and s100 calcium-binding protein for prediction of mortality in children resuscitated after cardiac arrest. Pediatr Cardiol. 2022;43:1659–1665. doi: 10.1007/s00246-022-02899-9 204. Scholefield BR, Tijssen J, Ganesan SL, Kool M, Topjian A, Couto TB, Guerguerian A-M; International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Electrophysiology testing for the prediction of survival with good neurological outcome after return of circulation following pediatric cardiac arrest: PLS TFSR. Accessed March 7, 2023. https://costr. ilcor.org/document/electrophysiology-testing-for-the-prediction-of-survival-with-good-neurological-outcome-after-return-of-circulation-followingpediatric-cardiac-arrest-pls-tfsr 205. Fung FW, Topjian AA, Xiao R, Abend NS. Early EEG features for outcome prediction after cardiac arrest in children. J Clin Neurophysiol. 2019;36:349– 357. doi: 10.1097/WNP.0000000000000591 206. Kirschen MP, Licht DJ, Faerber J, Mondal A, Graham K, Winters M, Balu R, Diaz-Arrastia R, Berg RA, Topjian A, et al. Association of MRI brain injury with outcome after pediatric out-of-hospital cardiac arrest. Neurology. 2021;96:e719–e731. doi: 10.1212/WNL.0000000000011217 207. Lin JJ, Lin YJ, Hsia SH, Kuo HC, Wang HS, Hsu MH, Chiang MC, Lin CY, Lin KL. Early clinical predictors of neurological outcome in children with asphyxial out-of-hospital cardiac arrest treated with therapeutic hypothermia. Front Pediatr. 2019;7:534. doi: 10.3389/fped.2019.00534 208. Ostendorf AP, Hartman ME, Friess SH. Early electroencephalographic findings correlate with neurologic outcome in children following cardiac arrest. Pediatr Crit Care Med. 2016;17:667–676. doi: 10.1097/PCC.0000000000000791 209. Topjian AA, Sanchez SM, Shults J, Berg RA, Dlugos DJ, Abend NS. Early electroencephalographic background features predict outcomes in children resuscitated from cardiac arrest. Pediatr Crit Care Med. 2016;17:547–557. doi: 10.1097/PCC.0000000000000740 210. Yang D, Ryoo E, Kim HJ. Combination of early EEG, brain CT, and ammonia level is useful to predict neurologic outcome in children resuscitated from cardiac arrest. Front Pediatr. 2019;7:223. doi: 10.3389/fped.2019.00223 211. McDevitt WM, Rowberry TA, Davies P, Bill PR, Notghi LM, Morris KP, Scholefield BR. The prognostic value of somatosensory evoked potentials in children after cardiac arrest: the SEPIA study. J Clin Neurophysiol. 2021;38:30–35. doi: 10.1097/wnp.0000000000000649 212. Kessler SK, Topjian AA, Gutierrez-Colina AM, Ichord RN, Donnelly M, Nadkarni VM, Berg RA, Dlugos DJ, Clancy RR, Abend NS. Short-term outcome prediction by electroencephalographic features in children treated with therapeutic hypothermia after cardiac arrest. Neurocrit Care. 2011;14:37–43. doi: 10.1007/s12028-010-9450-2 213. Bourgoin P, Barrault V, Joram N, Leclair Visonneau L, Toulgoat F, Anthoine E, Loron G, Chenouard A. The prognostic value of early amplitude-integrated electroencephalography monitoring after pediatric cardiac arrest. Pediatr Crit Care Med. 2020;248:255. doi: 10.1097/PCC.0000000000002171 214. Scholefield BR, Tijssen J, Ganesan SL, Kool M, Topjian A, Couto TB, Guerguerian A-M; International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Brain imaging for the prediction of survival with good neurological outcome after return of circulation following pediatric cardiac arrest: PLS TFSR. Accessed March 7, 2023. https://costr.ilcor.org/ document/brain-imaging-for-the-prediction-of-survival-with-good-neurological-outcome-after-return-of-circulation-following-pediatric-cardiacarrest-pls-tfsr 215. Starling RM, Shekdar K, Licht D, Nadkarni VM, Berg RA, Topjian AA. Early head CT findings are associated with outcomes after pediatric outof-hospital cardiac arrest. Pediatr Crit Care Med. 2015;16:542–548. doi: 10.1097/PCC.0000000000000404 216. Yang D, Ha SG, Ryoo E, Choi JY, Kim HJ. Multimodal assessment using early brain CT and blood pH improve prediction of neurologic outcomes after pediatric cardiac arrest. Resuscitation. 2019;137:7–13. doi: 10.1016/j.resuscitation.2019.01.033 217. Fink EL, Panigrahy A, Clark RSB, Fitz CR, Sittel D, Kochanek PM, Zuccoli G. Regional brain injury on conventional and diffusion weighted MRI is associated with outcome after pediatric cardiac arrest. Neurocrit Care. 2013;19:31–40. doi: 10.1007/s12028-012-9706-0 218. Fink EL, Wisnowski J, Clark R, Berger RP, Fabio A, Furtado A, Narayan S, Angus DC, Watson RS, Wang C, et al. Brain MR imaging and spectroscopy for outcome prognostication after pediatric cardiac arrest. Resuscitation. 2020;157:185–194. doi: 10.1016/j.resuscitation.2020.06.033 219. Yacoub M, Birchansky B, Mlynash M, Berg M, Knight L, Hirsch KG, Su F; Revive Initiative at Stanford Children’s Hospital. The prognostic value of quantitative diffusion-weighted MRI after pediatric cardiopulmonary arrest. Resuscitation. 2019;135:103–109. doi: 10.1016/j.resuscitation.2018.11.003 220. Lin JJ, Hsia SH, Wang HS, Chiang MC, Lin KL. Transcranial Doppler ultrasound in therapeutic hypothermia for children after resuscitation. Resuscitation. 2015;89:182–187. doi: 10.1016/j.resuscitation.2015.01.029 221. Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, et al. Part 7: neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132:S204–S241. doi: 10.1161/cir.0000000000000276 222. de Almeida MF, Guinsburg R, Sancho GA, Rosa IR, Lamy ZC, Martinez FE, da Silva RP, Ferrari LS, de Souza Rugolo LM, Abdallah VO, et al. Hypothermia and early neonatal mortality in preterm infants. J Pediatr. 2014;164:271– 275.e1. doi: 10.1016/j.jpeds.2013.09.049 223. Wilson E, Maier RF, Norman M, Misselwitz B, Howell EA, Zeitlin J, Bonamy AK; Effective Perinatal Intensive Care in Europe Research Group. Admission hypothermia in very preterm infants and neonatal mortality and morbidity. J Pediatr. 2016;175:61–67 e64. doi: 10.1016/j.jpeds.2016.04.016 224. Lunze K, Bloom DE, Jamison DT, Hamer DH. The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival. BMC Med. 2013;11:24. doi: 10.1186/1741-7015-11-24 225. Dawson JA, Ramaswamy VV, de Almeida MF, Trang J, Trevisanuto D, Nakwa F, Kamlin C, Weiner G, Wyckoff MH, Liley HG; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Maintaining normal temperature immediately after birth in preterm infants: NLS 5101 TF SR. Accessed February 17, 2023. https://costr.ilcor.org/document/maintaining-normal-temperature-immediately-after-birth-in-preterm-infants-nls5101-tf-sr 226. World Health Organization. Thermal protection of the newborn: a practical guide. 1997. Accessed February 8, 2021. https://apps.who.int/iris/bitstream/handle/10665/63986/WHO_RHT_MSM_97.2.pdf 227. Ahmed BT, Hussein MA, Monir H. Effect of plastic bag (vinyl bags) on prevention of hypothermia in preterm infants. Med J Cairo Univ. 2013;81:169– 173. 228. Bhavsar S, Kabra N, Avasthi B, Sharma S, Dash S, Tali S, Padhi P, Ahmed J. Efficacy and safety of polythene wrap in preventing hypothermia in preterm and low birth weight neonates during transport: a randomized controlled trial. Perinatology. 2015;16:23–30. 229. Chantaroj S, Techasatid W. Effect of polyethylene bag to prevent heat loss in preterm infants at birth: a randomized controlled trial. J Med Assoc Thai. 2011;94:S32–S37. 230. Chawla S, Amaram A, Gopal SP, Natarajan G. Safety and efficacy of Transwarmer mattress for preterm neonates: results of a randomized controlled trial. J Perinatol. 2011;31:780–784. doi: 10.1038/jp.2011.33 231. Farhadi R, Naderi M, Rahmani Z, Ghaffari V, Khalilian A. Effect of “ZIPKIF” plastic bag on prevention of hypothermia in preterm infants: a randomized controlled trial. J Mazandaran Univ Med Sci. 2012;22:19–26. 232. Ibrahim CP, Yoxall CW. Use of self-heating gel mattresses eliminates admission hypothermia in infants born below 28 weeks gestation. Eur J Pediatr. 2010;169:795–799. doi: 10.1007/s00431-009-1113-y 233. Knobel RB, Wimmer JE Jr, Holbert D. Heat loss prevention for preterm infants in the delivery room. J Perinatol. 2005;25:304–308. doi: 10.1038/sj.jp.7211289 Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e273 234. Lewis DA, Sanders LP, Brockopp DY. The effect of three nursing interventions on thermoregulation in low birth weight infants. Neonatal Netw. 2011;30:160–164. doi: 10.1891/0730-0832.30.3.160 235. Mathew B, Lakshminrusimha S, Sengupta S, Carrion V. Randomized controlled trial of vinyl bags versus thermal mattress to prevent hypothermia in extremely low-gestational-age infants. Am J Perinatol. 2013;30:317–322. doi: 10.1055/s-0032-1324700 236. McCarthy LK, Molloy EJ, Twomey AR, Murphy JF, O’Donnell CP. A randomized trial of exothermic mattresses for preterm newborns in polyethylene bags. Pediatrics. 2013;132:e135–e141. doi: 10.1542/peds.2013-0279 237. McCarthy LK, O’Donnell CP. Warming preterm infants in the delivery room: polyethylene bags, exothermic mattresses or both? Acta Paediatr. 2011;100:1534–1537. doi: 10.1111/j.1651-2227.2011.02375.x 238. McGrory L, Owen LS, Thio M, Dawson JA, Rafferty AR, Malhotra A, Davis PG, Kamlin COF. A randomized trial of conditioned or unconditioned gases for stabilizing preterm infants at birth. J Pediatr. 2018;193:47–53. doi: 10.1016/j.jpeds.2017.09.006 239. Meyer MP, Hou D, Ishrar NN, Dito I, te Pas AB. Initial respiratory support with cold, dry gas versus heated humidified gas and admission temperature of preterm infants. J Pediatr. 2015;166:245–250.e241. doi: 10.1016/j.jpeds.2014.09.049 240. Pinheiro JM, Boynton S, Furdon SA, Dugan R, Reu-Donlon C. Use of chemical warming packs during delivery room resuscitation is associated with decreased rates of hypothermia in very low-birth-weight neonates. Adv Neonatal Care. 2011;11:357–362. doi: 10.1097/ANC.0b013e318229aa8f 241. Reilly MC, Vohra S, Rac VE, Dunn M, Ferrelli K, Kiss A, Vincer M, Wimmer J, Zayack D, Soll RF; Vermont Oxford Network Heat Loss Prevention (HeLP) Trial Study Group Randomized trial of occlusive wrap for heat loss prevention in preterm infants. J Pediatr. 2015;166:262–268.e2. doi: 10.1016/j.jpeds.2014.09.068 242. Reilly MC, Vohra S, Rac VE, Zayack D, Wimmer J, Vincer M, Ferrelli K, Kiss A, Soll RF, Dunn M. Parallel exploratory RCT of polyethylene wrap for heat loss prevention in infants born at less than 24 weeks’ gestation. Neonatology. 2019;116:37–41. doi: 10.1159/000497253 243. Simon P, Dannaway D, Bright B, Krous L, Wlodaver A, Burks B, Thi C, Milam J, Escobedo M. Thermal defense of extremely low gestational age newborns during resuscitation: exothermic mattresses vs polyethylene wrap. J Perinatol. 2011;31:33–37. doi: 10.1038/jp.2010.56 244. Singh A, Duckett J, Newton T, Watkinson M. Improving neonatal unit admission temperatures in preterm babies: exothermic mattresses, polythene bags or a traditional approach? J Perinatol. 2010;30:45–49. doi: 10.1038/jp.2009.94 245. Smith J, Usher K, Alcock G, Buettner P. Application of plastic wrap to improve temperatures in infants born less than 30 weeks gestation: a randomized controlled trial. Neonatal Netw. 2013;32:235–245. doi: 10.1891/0730-0832.32.4.235 246. te Pas AB, Lopriore E, Dito I, Morley CJ, Walther FJ. Humidified and heated air during stabilization at birth improves temperature in preterm infants. Pediatrics. 2010;125:e1427–e1432. doi: 10.1542/peds.2009-2656 247. Trevisanuto D, Doglioni N, Cavallin F, Parotto M, Micaglio M, Zanardo V. Heat loss prevention in very preterm infants in delivery rooms: a prospective, randomized, controlled trial of polyethylene caps. J Pediatr. 2010;156:914– 917.e1. doi: 10.1016/j.jpeds.2009.12.021 248. Vohra S, Frent G, Campbell V, Abbott M, Whyte R. Effect of polyethylene occlusive skin wrapping on heat loss in very low birth weight infants at delivery: a randomized trial. J Pediatr. 1999;134:547–551. doi: 10.1016/s0022-3476(99)70238-6 249. Vohra S, Roberts RS, Zhang B, Janes M, Schmidt B. Heat Loss Prevention (HeLP) in the delivery room: a randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants. J Pediatr. 2004;145:750– 753. doi: 10.1016/j.jpeds.2004.07.036 250. Duryea EL, Nelson DB, Wyckoff MH, Grant EN, Tao W, Sadana N, Chalak LF, McIntire DD, Leveno KJ. The impact of ambient operating room temperature on neonatal and maternal hypothermia and associated morbidities: a randomized controlled trial. Am J Obstet Gynecol. 2016;214:505.e1–505. e7. doi: 10.1016/j.ajog.2016.01.190 251. Jia YS, Lin ZL, Lv H, Li YM, Green R, Lin J. Effect of delivery room temperature on the admission temperature of premature infants: a randomized controlled trial. J Perinatol. 2013;33:264–267. doi: 10.1038/jp.2012.100 252. Johannsen JKI, Vochem M, Neuberger P. Does a higher ambient temperature in the delivery room prevent hypothermia in preterm infants <1500 g? [in German]. Z Geburtshilfe Neonatol. 2017;221:235–240. doi: 10.1055/s-0043-118809 253. Kent AL, Williams J. Increasing ambient operating theatre temperature and wrapping in polyethylene improves admission temperature in premature infants. J Paediatr Child Health. 2008;44:325–331. doi: 10.1111/j.1440-1754.2007.01264.x 254. Gathwala G, Singh G, Kunal, Agrawal N. Safety and efficacy of vinyl bags in prevention of hypothermia of preterm neonates at birth. Indian J Public Health. 2010;54:24–26. doi: 10.4103/0019-557X.70543 255. Nimbalkar SM, Khanna AK, Patel DV, Nimbalkar AS, Phatak AG. Efficacy of polyethylene skin wrapping in preventing hypothermia in preterm neonates (<34 weeks): a parallel group non-blinded randomized control trial. J Trop Pediatr. 2019;65:122–129. doi: 10.1093/tropej/fmy025 256. Rohana J, Khairina W, Boo NY, Shareena I. Reducing hypothermia in preterm infants with polyethylene wrap. Pediatr Int. 2011;53:468–474. doi: 10.1111/j.1442-200X.2010.03295.x 257. Talakoub S, Shahbazifard Z, Armanian AM, Ghazavi Z. Effect of two polyethylene covers in prevention of hypothermia among premature neonates. Iran J Nurs Midwifery Res. 2015;20:322–326. 258. Cavallin F, Doglioni N, Allodi A, Battajon N, Vedovato S, Capasso L, Gitto E, Laforgia N, Paviotti G, Capretti MG, et al. Thermal management with and without servo-controlled system in preterm infants immediately after birth: a multicentre, randomised controlled study. Arch Dis Child Fetal Neonatal Ed. 2021;106:572–577. doi: 10.1136/archdischild-2020-320567 259. Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200to 2199-gram newborns. Acta Paediatr. 2004;93:779–785. doi: 10.1111/j.1651-2227.2004.tb03018.x 260. Linnér A, Klemming S, Sundberg B, Lilliesköld S, Westrup B, Jonas W, Skiöld B. Immediate skin-to-skin contact is feasible for very preterm infants but thermal control remains a challenge. Acta Paediatr. 2020;109:697–704. doi: 10.1111/apa.15062 261. Ramaswamy VV, de Almeida MF, Dawson JA, Trevisanuto D, Nakwa FL, Kamlin CO, Hosono S, Wyckoff MH, Liley HG; International Liaison Committee on Resuscitation Neonatal Life Support Task F. Maintaining normal temperature immediately after birth in late preterm and term infants: a systematic review and meta-analysis. Resuscitation. 2022;180:81–98. doi: 10.1016/j.resuscitation.2022.09.014 262. Arya S, Naburi H, Kawaza K, Newton S, Anyabolu CH, Bergman N, Rao SPN, Mittal P, Assenga E, Gadama L, et al. Immediate “kangaroo mother care” and survival of infants with low birth weight. N Engl J Med. 2021;384:2028– 2038. doi: 10.1056/NEJMoa2026486 263. Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, Guinsburg R, Hazinski MF, Morley C, Richmond S, et al. Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122:S516–S538. doi: 10.1161/circulationaha.110.971127 264. Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J, Guinsburg R, Hosono S, Isayama T, Kapadia VS, et al; Neonatal Life Support Collaborators. Neonatal life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):S185–S221. doi: 10.1161/CIR.0000000000000895 265. Kawakami MD, Kapadia VS, Strand M, Gately C, Costa-Nobre DT, Davis PG, de Almeida MF, El-Naggar W, Fabres JG, Fawke J, et al; International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force. Heart rate assessment methods in delivery room—diagnostic characteristics: NLS 5200 TF SR. Accessed February 17, 2023. https://costr.ilcor. org/document/heart-rate-assessment-methods-in-delivery-room-diagnostic-characteristics-nls-5200-tf-sr 266. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1:307–310. 267. Bland JM, Altman DG. Comparing methods of measurement: why plotting difference against standard method is misleading. Lancet. 1995;346:1085– 1087. doi: 10.1016/s0140-6736(95)91748-9 268. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8:135–160. doi: 10.1177/096228029900800204 269. Giavarina D. Understanding Bland Altman analysis. Biochem Med (Zagreb). 2015;25:141–151. doi: 10.11613/bm.2015.015 270. Montenij LJ, Buhre WF, Jansen JR, Kruitwagen CL, de Waal EE. Methodology of method comparison studies evaluating the validity of cardiac output monitors: a stepwise approach and checklist. Br J Anaesth. 2016;116:750– 758. doi: 10.1093/bja/aew094 271. Abbey NV, Mashruwala V, Weydig HM, Steven Brown L, Ramon EL, Ibrahim J, Mir IN, Wyckoff MH, Kapadia V. Electrocardiogram for heart rate evaluation during preterm resuscitation at birth: a randomized trial. Pediatr Res. 2022;91:1445–1451. doi: 10.1038/s41390-021-01731-z Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES December 12, 2023 Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 Berg et al 2023 ILCOR CoSTR Summary e274 272. Murphy MC, De Angelis L, McCarthy LK, O’Donnell CPF. Randomised study comparing heart rate measurement in newly born infants using a monitor incorporating electrocardiogram and pulse oximeter versus pulse oximeter alone. Arch Dis Child Fetal Neonatal Ed. 2019;104:F547–F550. doi: 10.1136/archdischild-2017-314366 273. Murphy MC, Jenkinson A, Coveney J, McCarthy LK, O’Donnell CPF. Randomised study of heart rate measurement in preterm newborns with ECG plus pulse oximetry versus oximetry alone. Arch Dis Child Fetal Neonatal Ed. 2021;106:438–441. doi: 10.1136/archdischild-2020-320892 274. Bjorland PA, Ersdal HL, Øymar K, Rettedal SI. Compliance with guidelines and efficacy of heart rate monitoring during newborn resuscitation: a prospective video study. Neonatology. 2020;117:175–181. doi: 10.1159/000506772 275. Bobillo-Perez S, Balaguer M, Jordan I, Batista-Muñoz A, Ramon M, Otero O, Sorribes C, Rodriguez-Fanjul J. Delivery room ultrasound study to assess heart rate in newborns: DELIROUS study. Eur J Pediatr. 2021;180:783– 790. doi: 10.1007/s00431-020-03776-4 276. Bush JB, Cooley V, Perlman J, Chang C. NeoBeat offers rapid newborn heart rate assessment. Arch Dis Child Fetal Neonatal Ed. 2021;106:550– 552. doi: 10.1136/archdischild-2020-320901 277. Dawson JA, Saraswat A, Simionato L, Thio M, Kamlin CO, Owen LS, Schmölzer GM, Davis PG. Comparison of heart rate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants. Acta Paediatr. 2013;102:955–960. doi: 10.1111/apa.12329 278. Henry C, Shipley L, Ward C, Mirahmadi S, Liu C, Morgan S, Crowe J, Carpenter J, Hayes-Gill B, Sharkey D. Accurate neonatal heart rate monitoring using a new wireless, cap mounted device. Acta Paediatr. 2021;110:72– 78. doi: 10.1111/apa.15303 279. Iglesias B, Rodríguez MJ, Aleo E, Criado E, Martí Nez-Orgado J, Arruza L. 3-Lead electrocardiogram is more reliable than pulse oximetry to detect bradycardia during stabilisation at birth of very preterm infants. Arch Dis Child Fetal Neonatal Ed. 2018;103:F233–F237. doi: 10.1136/archdischild-2016-311492 280. Iglesias B, Rodríguez MJ, Aleo E, Criado E, Herranz G, Moro M, Martínez Orgado J, Arruza L. Pulse oximetry versus electrocardiogram for heart rate assessment during resuscitation of the preterm infant [in Spanish]. An Pediatr (Barc). 2016;84:271–277. doi: 10.1016/j.anpedi.2015.08.012 281. Kamlin CO, Dawson JA, O’Donnell CP, Morley CJ, Donath SM, Sekhon J, Davis PG. Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room. J Pediatr. 2008;152:756–760. doi: 10.1016/j.jpeds.2008.01.002 282. Katheria A, Rich W, Finer N. Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation. Pediatrics. 2012;130:e1177–e1181. doi: 10.1542/peds.2012-0784 283. Mizumoto H, Tomotaki S, Shibata H, Ueda K, Akashi R, Uchio H, Hata D. Electrocardiogram shows reliable heart rates much earlier than pulse oximetry during neonatal resuscitation. Pediatr Int. 2012;54:205–207. doi: 10.1111/j.1442-200X.2011.03506.x 284. van Vonderen JJ, Hooper SB, Kroese JK, Roest AA, Narayen IC, van Zwet EW, te Pas AB. Pulse oximetry measures a lower heart rate at birth compared with electrocardiography. J Pediatr. 2015;166:49–53. doi: 10.1016/j.jpeds.2014.09.015 285. Kamlin CO, O’Donnell CP, Everest NJ, Davis PG, Morley CJ. Accuracy of clinical assessment of infant heart rate in the delivery room. Resuscitation. 2006;71:319–321. doi: 10.1016/j.resuscitation.2006.04.015 286. Cavallin F, Cori MS, Negash S, Azzimonti G, Vento G, Putoto G, Trevisanuto D. Heart rate determination in newborns at risk for resuscitation in a lowresource setting: a randomized controlled trial. J Pediatr. 2020;221:88–92. e1. doi: 10.1016/j.jpeds.2020.02.026 287. Murphy MC, De Angelis L, McCarthy LK, O’Donnell CPF. Comparison of infant heart rate assessment by auscultation, ECG and oximetry in the delivery room. Arch Dis Child Fetal Neonatal Ed. 2018;103:F490–F492. doi: 10.1136/archdischild-2017-314367 288. Treston BP, Semberova J, Kernan R, Crothers E, Branagan A, O’Cathain N, Miletin J. Assessment of neonatal heart rate immediately after birth using digital stethoscope, handheld ultrasound and electrocardiography: an observational cohort study. Arch Dis Child Fetal Neonatal Ed. 2019;104:F227. doi: 10.1136/archdischild-2018-315619 289. Solevåg AL, Monnelly VJ, Josephsen JB, Isayama T, de Almeida MF, Guinsburg R, Costa-Nobre DT, Davis PG, El-Naggar W, Fabres JG, et al; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Exhaled CO2 to guide non-invasive ventilation at birth: NLS 5350; TFSR. Accessed February 17, 2023. https://costr.ilcor.org/document/exhaled-co2-to-guide-non-invasive-ventilation-at-birth-nls-5350-tfsr 290. Blank D, Rich W, Leone T, Garey D, Finer N. Pedi-cap color change precedes a significant increase in heart rate during neonatal resuscitation. Resuscitation. 2014;85:1568–1572. doi: 10.1016/j.resuscitation.2014.08.027 291. Blank DA, Badurdeen S, Omar FKC, Jacobs SE, Thio M, Dawson JA, Kane SC, Dennis AT, Polglase GR, Hooper SB, et al. Baby-directed umbilical cord clamping: a feasibility study. Resuscitation. 2018;131:1–7. doi: 10.1016/j.resuscitation.2018.07.020 292. Finer NN, Rich W, Wang C, Leone T. Airway obstruction during mask ventilation of very low birth weight infants during neonatal resuscitation. Pediatrics. 2009;123:865–869. doi: 10.1542/peds.2008-0560 293. Hawkes GA, Finn D, Kenosi M, Livingstone V, O’Toole JM, Boylan GB, O’Halloran KD, Ryan AC, Dempsey EM. A randomized controlled trial of end-tidal carbon dioxide detection of preterm infants in the delivery room. J Pediatr. 2017;182:74–78.e2. doi: 10.1016/j.jpeds.2016.11.006 294. Kang LJ, Cheung PY, Pichler G, O’Reilly M, Aziz K, Schmölzer GM. Monitoring lung aeration during respiratory support in preterm infants at birth. PLoS One. 2014;9:e102729. doi: 10.1371/journal.pone.0102729 295. Kong JY, Rich W, Finer NN, Leone TA. Quantitative end-tidal carbon dioxide monitoring in the delivery room: a randomized controlled trial. J Pediatr. 2013;163:104–108.e1. doi: 10.1016/j.jpeds.2012.12.016 296. Mizumoto H, Iki Y, Yamashita S, Hata D. Expiratory CO2 as the first sign of successful ventilation during neonatal resuscitation. Pediatr Int. 2015;57:186–188. doi: 10.1111/ped.12553 297. Ngan AY, Cheung PY, Hudson-Mason A, O’Reilly M, van Os S, Kumar M, Aziz K, Schmölzer GM. Using exhaled CO(2) to guide initial respiratory support at birth: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2017;102:F525–F531. doi: 10.1136/archdischild-2016-312286 298. Muir JD, Randalls PB, Smith GB. End tidal carbon dioxide detector for monitoring cardiopulmonary resuscitation. BMJ. 1990;301:41–42. doi: 10.1136/bmj.301.6742.41-b 299. Kattwinkel J, Niermeyer S, Nadkarni V, Tibballs J, Phillips B, Zideman D, Van Reempts P, Osmond M. Resuscitation of the newly born infant: an advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation. Eur J Pediatr. 1999;158:345–358. doi: 10.1007/s004310051090 300. Ramachandran S, Bruckner M, Wyckoff MH, Schmölzer GM. Chest compressions in newborn infants: a scoping review [published online December 1 2022]. Arch Dis Child Fetal Neonatal Ed. doi: 10.1136/archdischild-2022-324529. https://fn.bmj.com/content/early/2022/12/01/archdischild-2022-324529.long 301. Ramachandran S, Bruckner M, Wyckoff MH, Smölzer GM; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Heart rate for starting neonatal chest compressions: NLS 5500 TF ScR. Accessed February 17, 2023. https://costr.ilcor.org/document/nls-5500-heart-ratefor-starting-neonatal-chest-compressions-tfscr 302. Agrawal V, Lakshminrusimha S, Chandrasekharan P. Chest compressions for bradycardia during neonatal resuscitation: do we have evidence? Children (Basel). 2019;6:119. doi: 10.3390/children6110119 303. Ramachandran S, Bruckner M, Wyckoff MH, Schmölzer GM; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Supplemental oxygen during chest compressions: NLS 5503 ScR. Accessed February 17, 2023. https://costr.ilcor.org/document/supplementaloxygen-during-chest-compressions-nls-5503-scr 304. Dannevig I, Solevåg AL, Saugstad OD, Nakstad B. Lung injury in asphyxiated newborn pigs resuscitated from cardiac arrest: the impact of supplementary oxygen, longer ventilation intervals and chest compressions at different compression-to-ventilation ratios. Open Respir Med J. 2012;6:89–96. doi: 10.2174/1874306401206010089 305. Dannevig I, Solevåg AL, Sonerud T, Saugstad OD, Nakstad B. Brain inflammation induced by severe asphyxia in newborn pigs and the impact of alternative resuscitation strategies on the newborn central nervous system. Pediatr Res. 2013;73:163–170. doi: 10.1038/pr.2012.167 306. Linner R, Werner O, Perez-de-Sa V, Cunha-Goncalves D. Circulatory recovery is as fast with air ventilation as with 100% oxygen after asphyxia-induced cardiac arrest in piglets. Pediatr Res. 2009;66:391–394. doi: 10.1203/PDR.0b013e3181b3b110 307. Solevåg AL, Dannevig I, Nakstad B, Saugstad OD. Resuscitation of severely asphyctic newborn pigs with cardiac arrest by using 21% or 100% oxygen. Neonatology. 2010;98:64–72. doi: 10.1159/000275560 308. Solevåg AL, Garcia-Hidalgo C, Cheung PY, Lee TF, O’Reilly M, Schmölzer GM. Ventilation with 18, 21, or 100% oxygen during cardiopulmonary resuscitation of asphyxiated piglets: a randomized controlled animal trial. Neonatology. 2020;117:102–110. doi: 10.1159/000504494 Downloaded from http://ahajournals.org by on February 23, 2024 CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e187–e280. DOI: 10.1161/CIR.0000000000001179 December 12, 2023 Berg et al 2023 ILCOR CoSTR Summary e275 309. Solevåg AL, Schmölzer GM, O’Reilly M, Lu M, Lee TF, Hornberger LK, Nakstad B, Cheung PY. Myocardial perfusion and oxidative stress after 21% vs. 100% oxygen ventilation and uninterrupted chest compressions in severely asphyxiated piglets. Resuscitation. 2016;106:7–13. doi: 10.1016/j.resuscitation.2016.06.014 310. Ramachandran S, Bruckner M, Wyckoff MH, Schmölzer GM; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Neonatal chest compression technique (other techniques versus two thumb): NLS 5501 TF ScR. Accessed February 17, 2023. https://costr.ilcor. org/document/nls-5501-neonatal-chest-compression-technique-othertechniques-versus-two-thumb-nls-tf-scr 311. Cheung PY, Huang H, Xu C, Liu JQ, Ting JY, Wong R, Lee W, Xue Y, Yi Y. Comparing the quality of cardiopulmonary resuscitation performed at the over-the-head position and lateral position of neonatal manikin. Front Pediatr. 2019;7:559. doi: 10.3389/fped.2019.00559 312. Christman C, Hemway RJ, Wyckoff MH, Perlman JM. The two-thumb is superior to the two-finger method for administering chest compressions in a manikin model of neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed. 2011;96:F99–F101. doi: 10.1136/adc.2009.180406 313. Dorfsman ML, Menegazzi JJ, Wadas RJ, Auble TE. Two-thumb vs. two-finger chest compression in an infant model of prolonged cardiopulmonary resuscitation. Acad Emerg Med. 2000;7:1077–1082. doi: 10.1111/j.1553-2712.2000.tb01255.x 314. Fakhraddin BZ, Shimizu N, Kurosawa S, Sakai H, Miyasaka K, Mizutani S. New method of chest compression for infants in a single rescuer situation: thumb-index finger technique. J Med Dent Sci. 2011;58:15–22. 315. Huynh TK, Hemway RJ, Perlman JM. The two-thumb technique using an elevated surface is preferable for teaching infant cardiopulmonary resuscitation. J Pediatr. 2012;161:658–661. doi: 10.1016/j.jpeds.2012.03.019 316. Jang HY, Wolfe H, Hsieh TC, Abbadessa MK, Myers S, Nadkarni V, Donoghue A. Infant chest compression quality: a video-based comparison of two-thumb versus one-hand technique in the emergency department. Resuscitation. 2018;122:36–40. doi: 10.1016/j.resuscitation.2017.11.044 317. Jiang J, Zou Y, Shi W, Zhu Y, Tao R, Jiang Y, Lu Y, Tong J. Two-thumbencircling hands technique is more advisable than 2-finger technique when lone rescuer performs cardiopulmonary resuscitation on infant manikin. Am J Emerg Med. 2015;33:531–534. doi: 10.1016/j.ajem.2015.01.025 318. Jo CH, Cho GC, Lee CH. Two-thumb encircling technique over the head of patients in the setting of lone rescuer infant CPR occurred during ambulance transfer: a crossover simulation study. Pediatr Emerg Care. 2017;33:462–466. doi: 10.1097/pec.0000000000000833 319. Jo CH, Jung HS, Cho GC, Oh YJ. Over-the-head two-thumb encircling technique as an alternative to the two-finger technique in the in-hospital infant cardiac arrest setting: a randomised crossover simulation study. Emerg Med J. 2015;32:703–707. doi: 10.1136/emermed-2014-203873 320. Jung WJ, Hwang SO, Kim HI, Cha YS, Kim OH, Kim H, Lee KH, Cha KC. “Knocking-fingers” chest compression technique in infant cardiac arrest: single-rescuer manikin study. Eur J Emerg Med. 2019;26:261–265. doi: 10.1097/mej.0000000000000539 321. Ladny JR, Smereka J, Rodríguez-Núñez A, Leung S, Ruetzler K, Szarpak L. Is there any alternative to standard chest compression techniques in infants? A randomized manikin trial of the new “2-thumb-fist” option. Medicine (Baltimore). 2018;97:e9386. doi: 10.1097/md.0000000000009386 322. Lee SU, Kim DK, Chang I, Jung JY, Paek SH, Park JW, Lee JH, Kwak YH. Two-thumb encircling technique with a novel compression assist device provides safe and effective chest compressions in infants. Pediatr Emerg Care. 2020;36:e700–e703. doi: 10.1097/pec.0000000000001738 323. Lee SY, Hong JY, Oh JH, Son SH. The superiority of the two-thumb over the two-finger technique for single-rescuer infant cardiopulmonary resuscitation. Eur J Emerg Med. 2018;25:372–376. doi: 10.1097/mej.0000000000000461 324. Paek SH, Kim DK, Lee JH, Kwak YH. Comparison of standard and alternative methods for chest compressions in a single rescuer infant CPR: a prospective simulation study. PLoS One. 2019;14:e0226632. doi: 10.1371/journal.pone.0226632 325. Pellegrino JL, Bogumil D, Epstein JL, Burke RV. Two-thumb-encircling advantageous for lay responder infant CPR: a randomised manikin study. Arch Dis Child. 2019;104:530–534. doi: 10.1136/archdischild-2018-314893 326. Reynolds C, Cox J, Livingstone V, Dempsey EM. Rescuer exertion and fatigue using two-thumb vs. two-finger method during simulated neonatal cardiopulmonary resuscitation. Front Pediatr. 2020;8:133. doi: 10.3389/fped.2020.00133 327. Rodriguez-Ruiz E, Martínez-Puga A, Carballo-Fazanes A, Abelairas-Gómez C, Rodríguez-Nuñez A. Two new chest compression methods might challenge the standard in a simulated infant model. Eur J Pediatr. 2019;178:1529–1535. doi: 10.1007/s00431-019-03452-2 328. Saini SS, Gupta N, Kumar P, Bhalla AK, Kaur H. A comparison of two-fingers technique and two-thumbs encircling hands technique of chest compression in neonates. J Perinatol. 2012;32:690–694. doi: 10.1038/jp.2011.167 329. Smereka J, Bielski K, Ladny JR, Ruetzler K, Szarpak L. Evaluation of a newly developed infant chest compression technique: a randomized crossover manikin trial. Medicine (Baltim). 2017;96:e5915. doi: 10.1097/md.0000000000005915 330. Smereka J, Kasiński M, Smereka A, Ładny JR, Szarpak L. The quality of a newly developed infant chest compression method applied by paramedics: a randomised crossover manikin trial. Kardiol Pol. 2017;75:589–595. doi: 10.5603/KP.a2017.0015 331. Smereka J, Szarpak L, Ladny JR, Rodriguez-Nunez A, Ruetzler K. A novel method of newborn chest compression: a randomized crossover simulation study. Front Pediatr. 2018;6:159. doi: 10.3389/fped.2018.00159 332. Smereka J, Szarpak L, Rodríguez-Núñez A, Ladny JR, Leung S, Ruetzler K. A randomized comparison of three chest compression techniques and associated hemodynamic effect during infant CPR: a randomized manikin study. Am J Emerg Med. 2017;35:1420–1425. doi: 10.1016/j.ajem.2017.04.024 333. Smereka J, Szarpak L, Smereka A, Leung S, Ruetzler K. Evaluation of new two-thumb chest compression technique for infant CPR performed by novice physicians: a randomized, crossover, manikin trial. Am J Emerg Med. 2017;35:604–609. doi: 10.1016/j.ajem.2016.12.045 334. Udassi S, Udassi JP, Lamb MA, Theriaque DW, Shuster JJ, Zaritsky AL, Haque IU. Two-thumb technique is superior to two-finger technique during lone rescuer infant manikin CPR. Resuscitation. 2010;81:712–717. doi: 10.1016/j.resuscitation.2009.12.029 335. Whitelaw CC, Slywka B, Goldsmith LJ. Comparison of a two-finger versus two-thumb method for chest compressions by healthcare providers in an infant mechanical model. Resuscitation. 2000;43:213–216. doi: 10.1016/s0300-9572(99)00145-8 336. Yang D, Kim KH, Oh JH, Son S, Cho J, Seo KM. Development and evaluation of a new chest compression technique for cardiopulmonary resuscitation in infants. Pediatr Cardiol. 2019;40:1217–1223. doi: 10.1007/s00246-019-02135-x 337. Na JU, Choi PC, Lee HJ, Shin DH, Han SK, Cho JH. A vertical two-thumb technique is superior to the two-thumb encircling technique for infant cardiopulmonary resuscitation. Acta Paediatr. 2015;104:e70–e75. doi: 10.1111/apa.12857 338. Kim YS, Oh JH, Kim CW, Kim SE, Lee DH, Hong JY. Which fingers should we perform two-finger chest compression technique with when performing cardiopulmonary resuscitation on an infant in cardiac arrest? J Korean Med Sci. 2016;31:997–1002. doi: 10.3346/jkms.2016.31.6.997 339. Park JW, Jung JY, Kim J, Kwak YH, Kim DK, Lee JC, Ham EM, Hwang S, Kwon H. A novel infant chest compression assist device using a palm rather than fingers: a randomized crossover trial. Prehosp Emerg Care. 2019;23:74–82. doi: 10.1080/10903127.2018.1471559 340. Martin PS, Kemp AM, Theobald PS, Maguire SA, Jones MD. Do chest compressions during simulated infant CPR comply with international recommendations? Arch Dis Child. 2013;98:576–581. doi: 10.1136/archdischild-2012-302583 341. Ramachandran S, Bruckner M, Wyckoff MH, Smölzer GM; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Compression ventilation ratio for neonatal CPR: NLS 5504 TF ScR. Accessed February 17, 2023. https://costr.ilcor.org/document/compressionventilation-ratio-for-neonatal-cpr-nls-5504-tf-scr 342. Aggelina A, Pantazopoulos I, Giokas G, Chalkias A, Mavrovounis G, Papalois A, Douvanas A, Xanthos T, Iacovidou N. Continuous chest compressions with asynchronous ventilation improve survival in a neonatal swine model of asphyxial cardiac arrest. Am J Emerg Med. 2021;48:60–66. doi: 10.1016/j.ajem.2021.04.009 343. Boldingh AM, Jensen TH, Bjørbekk AT, Solevåg AL, Nakstad B. Rescuers’ physical fatigue with different chest compression to ventilation methods during simulated infant cardiopulmonary resuscitation. J Matern Fetal Neonatal Med. 2016;29:3202–3207. doi: 10.3109/14767058.2015.1119115 344. Boldingh AM, Solevåg AL, Aasen E, Nakstad B. Resuscitators who compared four simulated infant cardiopulmonary resuscitation methods favoured the three-to-one compression-to-ventilation ratio. Acta Paediatr. 2016;105:910–916. doi: 10.1111/apa.13339 345. Dellimore KH, Scheffer C, Smith J, Van Den Heever DJ, Lloyd DL. Evaluating the influence of ventilation and ventilation-compression synchronization on chest compression force and depth during simulated neonatal Downloaded from http://ahajournals.org by on February 23, 2024 [Document text truncated for crawler view.]