2025+ILCOR科学治疗建议共识：基本生命支持

INTRODUCTION

This is the 2025 International Liaison Committee on Re-suscitation(ILCOR) Consensus on Science With Treat-ment Recommendations(CoSTR), from the ILCOR Basic Life Support(BLS) Task Force. All reviews conducted by the BLS Task Force in the last 12 months are included;reviews conducted and published since the 2020 publi-cation are also summarized to provide a single reference document for readers. The BLS Task Force work present-ed here encompasses 33 questions reviewed in some ca-pacity, including 22 systematic reviews (SysRevs). Draft CoSTRs for all topics evaluated with SysRevs were post-ed on a rolling basis 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. The task force considered public feedback and provided responses. All CoSTRs are now available online, adding to the existing CoSTR statements.

Although only SysRevs can generate a full CoSTR and new treatment recommendations, many other topics were evaluated with more streamlined processes, includ-ing scoping reviews (ScopRevs) and evidence updates(EvUps). Good practice statements, which represent the expert opinion of the task force in light of very limited or no direct evidence, can be generated after ScopRevs and occasionally after EvUps in cases where the task force thinks providing guidance is especially important.

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A separate article in this issue includes the full details of the evidence evaluation process.2

This summary statement contains the final wording of the treatment recommendations and good practice statements as approved by the ILCOR BLS Task Force as well as summaries of the key evidence identified. The year that treatment recommendations or good practice statements were generated or last updated by a Sys-Rev is provided in parentheses. In cases where existing treatment recommendations have changed for 2025, the prior recommendations are also presented so the reader can easily see that has changed. SysRevs include evidence-to-decision highlights and knowledge gaps,and ScopRevs summarize Task Force insights on spe-cific topics and include evidence-to-decision highlights if good practice statements are generated. Links to the published reviews and full online CoSTRs are provided in the corresponding sections. Evidence-to-decision tables for SysRevs are provided in Appendix A, and the com-plete EvUp worksheets are provided in Appendix B. A summary of treatment recommendation changes and knowledge gaps is provided in Appendix C.

Most topics are presented using the population, inter-vention, comparator, outcomes, study design, and time frame format. To minimize redundancy, the study designs have been removed from the text except in cases where the designs differed from the BLS standard criteria. The standard study designs included are randomized clini-cal trials (RCTs) and nonrandomized studies (non-RCTs,interrupt times series, controlled before-and-after stud-ies, and cohort studies) were eligible for inclusion. Case series, case reports, animal studies, and unpublished studies (conference abstracts, trial protocols) were excluded. All languages were included, provided there was an English abstract.

Two nodal reviews that included the BLS Task Force can be found in other CoSTR sections (Family Presence During Resuscitation3 in Education, Implementation, and Teams and Resuscitation of Durable Mechanical Circula-tory Supported Patients4 in Advanced Life Support). The following topics are addressed in this BLS Task Force CoSTR:

● Cardiopulmonary resuscitation(CPR) by rescuers wearing personal protective equipment (BLS 2003:SysRev 2023, EvUp 2025)

● Bystander (without dispatcher-assisted instruc-tions) chest compression-only CPR versus conven-tional CPR (BLS 2100: SysRev 2025)

● Optimization of dispatcher-assisted recognition of out-of-hospital cardiac arrest(OHCA)(BLS 2102:ScopRev 2024, EvUp 2025)

● Optimization of dispatcher-assisted CPR (BLS 2113: ScopRev 2024, EvUp 2025)

● Dispatcher-assisted chest compression-only CPR versus conventional CPR (BLS 2112: SysRev 2025)

● Optimization of dispatcher-assisted automated external defibrillator (AED) retrieval and use (BLS 2120: ScopRev 2024)

● Drone AED delivery(BLS 2122: ScopRev, 2023 CoSTR summary;EvUp 2025)

● AED accessibility: locked cabinets(BLS 2123:ScopRev 2025)

● Starting CPR (compressions-airway-breathing [CAB] versus airway-breathing-compressions[ABC]) (BLS 2201: SysRev 2025)

• Compression-ventilation ratio(BLS 2202: SysRev 2025)

● Duration of CPR cycles(BLS 2212: SysRev 2025)

● Emergency medical services (EMS) continuous-chest compression CPR versus conventional CPR (BLS 2221: SysRev 2025)

● In-hospital continuous-chest compression CPR versus conventional CPR (BLS 2222: SysRev 2025)

● Hand position during compressions (BLS 2502:SysRev 2025)

● Head-up CPR(BLS 2503: SysRev 2025)

● Minimizing pauses in compressions (BLS 2504:SysRev 2022, EvUp 2025)

● Optimal surface for CPR(BLS 2510: SysRev 2024)

● Feedback for CPR quality (BLS 2511: ScopRev 2024)

● Passive ventilation techniques(BLS 2403: SysRev 2022,EvUp 2025)

● Real-time ventilation quality feedback devices (BLS 2402: ScopRev 2025)

● Paddle/pad size and placement in adults(BLS 2601: SysRev 2025)

● Removal of bra prior to defibrillation (BLS 2604:ScopRev 2025)

● Effectiveness of ultraportable/pocket AEDs (BLS 2603: ScopRev 2024)

● Immediate resuscitation in water or on boat in drowning(BLS 2702/2703: ScopRev 2021, SysRev 2023, EvUp 2025)

● Starting CPR(CAB versus ABC) in drowning(BLS 2704: ScopRev 2023, SysRev 2024, EvUp 2025)

● Chest compression-only CPR in drowning(BLS 2705, ServcRev 2023, SysRev 2023, EvUp 2025)

● Ventilation equipment in cardiac arrest follow-ing drowning(BLS 2706: ScopRev 2023, SysRev 2023, SysRev 2024; ScopRev 2023, SysRev 2023, EvUp 2025)

● Prehospital oxygen administration following drown-ing(BLS 2707: SysRev 2023, EvUp 2025)

● AED use versus CPR first in drowning(BLS 2708:ScopRev 2023, SysRev 2023, EvUp 2025)

● Public access defibrillation (PAD) programs for drowning(BLS 2709: SysRev 2023, EvUp 2025)

● CPR during transport (BLS 2715: SysRev 2022,EvUp 2025)

● CPR in obese patients (BLS 2720: ScopRev 2025)

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Readers are encouraged to monitor the ILCOR web- site $^{1}$ to provide feedback on planned SysRevs and to pro- vide comments when additional draft reviews are posted.

SAFETY AND PREVENTION

CPR by Rescuers Wearing Personal Protective Equipment (BLS 2003: SysRev 2023, EvUp 2025)

A 2023 SysRev and 2025 EvUp examined the impact of rescuers wearing personal protective equipment on pa-tient and CPR outcomes. The details of this review can be found in the SysRev,5 the 2023 CoSTR summary 67 and on the ILCOR website. ${ }^{8}$ The 2025 EvUp is provided in Appendix B.

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest (including simulated cardiac arrest)

● Intervention: CPR by rescuers wearing personal protective equipment

● Comparator: CPR by rescuers not wearing personal protective equipment

• Outcomes:

- Critical: Survival to discharge, return of spontane-ous circulation(ROSC)

- Important: CPR quality, time to the procedure of interest, and rescuer's fatigue and neuropsychiatric performance such as concentration and dexterity

● Time frame: May 23,2022,to August 9,2024

Summary of Evidence

The EvUp identified 4 additional studies. ${ }^{9-12}$ Because the new evidence does not alter the current treatment rec-ommendations, an update to the existing SysRev is not warranted.

Treatment Recommendations (2023)

We recommend monitoring for fatigue in all rescuers performing CPR (good practice statement).

We suggest increased vigilance for fatigue in rescu-ers wearing personal protective equipment (weak recom-mendation, very low-certainty evidence).

RECOGNITION AND EARLY ACCESS

Bystander Chest Compression-Only CPR(Without Dispatcher Assistance)(BLS 2100,SysRev2025)

Rationale for Review

The previous SysRev ${ }^{13}$ and existing ILCOR treatment recommendation were first published in 2017.14,15 This

topic was prioritized because it had not been reviewed since 2017. The SysRev was registered on Prospec-tive Register of Systematic Reviews (PROSPERO)(CRD42024559318), and the full CoSTR for adults can be found on the ILCOR website. ${ }^{17}$ To inform the provision of immediate bystander CPR, it was decided to examine this question without cases where dispatcher-assisted CPR (DA-CPR) instructions were provided. Four studies that included cases with DA-CPR and were previously included in this CoSTR ${ }^{18-21}$ have been moved to the DA-CPR CoSTR.

Population, Intervention, Comparator, Outcome,Study Design, and Time Frame

● Population: Adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest

● Intervention: Chest compression-only CPR without dispatcher assistance

● Comparator: Conventional CPR with compressions and ventilations without dispatcher assistance

• Outcomes:

- Critical: Favorable neurological survival (as mea-sured by Cerebral Performance Category [CPC]or modified Rankin Scale [mRS]) at discharge or 30 days and at any time interval after 30 days

-Important: Survival to discharge or 30 days, survival to hospital admission, survival to any time interval after discharge or 30 days survival, survival or produced by any indicator or score after discharge or 30 days survival, ROC, quality of life as measured by any indicator or score

• Study design: In addition to standard criteria, obser-vational studies that reported only unadjusted data were excluded.

• Time frame: Because the search terms were revised,17 the search was all years to October 21,2024

Consensus on Science

No new studies that directly addressed this topic were found. The evidence remains 3 observational studies that compared bystander chest compression-only CPR with conventional CPR at a ratio of 15:22,23 and 30:224 in adults without DA-CPR instructions. Because 15:2 CPR is no longer recommended, all outcomes with these studies were downgraded for indirectness. No data was available from the included studies for the outcome of favorable neurological survival. Data for this outcome is drawn from a study of combined bystander-only CPR and DA-CPR with a high prevalence of bystander-only CPR.19 The evidence is summarized in Table 1.

Treatment Recommendations (2025, Unchanged From 2017)

We recommend that chest compressions be performed for all adults in cardiac arrest (good practice statement).

We suggest that bystanders who are trained, able,and willing, give chest compressions with rescue breaths

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

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

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

for adults in cardiac arrest (weak recommendation, very low-certainty evidence).

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is included in Appendix A.

In making these recommendations, the task force acknowledged the very low-certainty evidence in com-parison with 15:2 CPR but placed greater emphasis on the need to give chest compressions in adult CPR and the potential to increase rates of bystander CPR with chest compression-only CPR or compression-focused CPR in adults.20,25-27 The task force also considered the following:

● The existing evidence suggests chest com-sion-only CPR is comparable to 15:2 CPR in adults.Given the included studies were conducted without dispatcher assistance, it could be assumed that the CPR was performed by CPR-trained individuals or off-duty health care professionals.

● Three additional studies reported no difference in unadjusted patient outcomes between chest com-pression-only CPR and conventional CPR.28-30 One of these studies, conducted in the 1980s, examined the impact of CPR quality. Using combined objective and subjective measures, this study reported higher unadjusted survival when 15:2 was performed cor-rectly(good technique and effect), compared with incorrectly(31% versus 8%) or when compared with chest compression-only CPR(31% versus 20%).30 Rates of correctly applied 15:2 were higher in bystanders who were health care professionals than in lay bystanders(58% versus 42%).30

● A pilot RCT, including high rates of DA-CPR,showed no difference in survival at 1 day between chest compression-only CPR and conventional CPR when delivered by trained layers.31

● Chest compression-only CPR is preferred by the public$^{32,33}$ and easier to learn and recall.

● A literature review reported that chest compres-sion-only CPR results in a shorter time to initiate CPR and a higher total number of chest compres-sions.34 However, as it continues, rescuers may experience fatigue, which can reduce the depth of compressions compared with those delivered in conventional CPR with pauses for breaths. ${}^{34}$

● Opening the airway and delivering ventilations are technical skills, and bystanders, especially if untrained or minimally trained, are typically unable to deliver effective ventilations during simulated CPR.35

● Both types of CPR are better than no CPR, and both should be taught in BLS/CPR training.

Knowledge Gaps

● The effect on outcomes of chest compression-only CPR compared with 30:2 CPR without dispatcher assistance

● Data in children are needed.

Optimization of Dispatcher-Assisted Recognition of OHCA (BLS 2102: ScopRev 2024, EvUp 2025)

This topic was first reviewed in an ILCOR nodal Sys-Rev in 2020,36 with treatment recommendations for dispatcher-assisted recognition of OHCA published in the 2020 CoSTR.37,38 In 2024, the BLS Task Force de-cided to conduct a ScopRev to examine the evidence for interventions aiming to optimize dispatcher-assisted rec-ognition of OHCA, with an EvUp conducted in 2025. The details of this review can be found in the ScopRev,39 in the 2024 CoSTR summary,40,41 and on the ILCOR web-site.42 The 2025 EvUp is provided in Appendix B.

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children who are in cardiac arrest outside of a hospital

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● Intervention: Factors and interventions that improve dispatcher-assisted recognition of cardiac arrest

● Outcomes: Dispatcher-assisted recognition of car-diac arrest

● Time frame:June 2,2023,to November 4,2024

Summary of Evidence

The EvUp identified 2 additional studies.43,44 The new evi-dence provided by these studies does not warrant a new SysRev.

Treatment Recommendations (2020)

We recommend that dispatch centers implement a stan-dardized algorithm and/or standardized criteria to im-mediately determine if a patient is in cardiac arrest at the time of emergency call (strong recommendation, very low-certainty evidence).

We suggest that dispatch centers monitor and track diagnostic capability (good practice statement).

We suggest that dispatch centers look for ways to optimize sensitivity (minimize false negatives) (good practice statement).

The existing evidence did not support a good prac-tice statement for interventions to improve dispatcher-assisted recognition.

Optimization of Dispatcher-Assisted CPR(BLS 2113: ScopRev 2024, EvUp 2025)

This topic was last reviewed in an ILCOR nodal Sys-Rev in 2019, with treatment recommendations for dispatcher-assisted recognition of OHCA published in the 2019 CoSTR summary.45,46 In 2024, the BLS task force decided to conduct a ScopRev to examine the evi-dence for interventions to optimize DA-CPR instructions,with an EvUp conducted in 2025. The details of this re-view can be found in the ScopRev,47 the 2024 CoSTR summary,40,41 and on the ILCOR website.48 The 2025 EvUp is provided in Appendix B.

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children with OHCA when DA-CPR is implemented

● Intervention: Interventions used in addition to DA-CPR

● Comparators: Nonmodified DA-CPR

• Outcomes: Any outcomes

● Time frame: May 17,2023,to November 1,2024

Summary of Evidence

The EvUp identified 9 additional studies. ${ }^{49-57}$ The new evidence does not warrant a new SysRev.

Treatment Recommendations (2019 and 2024)

We recommend that emergency medical dispatch centers have systems in place to enable call handlers to provide

CPR instructions for adult patients in cardiac arrest(strong recommendation, very low-certainty evidence).

We recommend that emergency medical dispatchers provide CPR instructions (when deemed necessary) for adult patients in cardiac arrest (strong recommendation,very low-certainty evidence).

The existing evidence did not support a good prac-tice statement for interventions to improve DA-CPR instructions.

Dispatcher-Assisted Chest Compression-Only CPR (SysRev 2025)

Rationale for Review

The previous SysRev ${ }^{13}$ and existing ILCOR treatment recommendation were first published in 2017.14,15 This topic was prioritized for a detailed review because it had not been reviewed since 2017. The SysRev was regis-tered on PROSPERO (CRD42024559318), and the full CoSTR can be found on the ILCOR website. ${ }^{58}$

Population, Intervention, Comparator, Outcome,Study Design, and Time Frame

● Population: Adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest

● Intervention: Dispatcher-assisted chest compres-sion-only CPR

● Comparators: Dispatcher-assisted conventional CPR with compressions and ventilations

● Study design: In addition to standard criteria, obser-vational studies that reported only unadjusted data were excluded.

• Outcomes:

- Critical: Favorable neurological survival(as mea-sured by CPC or mRS) at discharge or 30 days and at any time interval after 30 days

- Important: Survival to discharge or 30 days, sur-vival to hospital admission, survival to any time interval after discharge or 30-days survival,ROSC,quality of life as measured by any indica-tor or score

● Time frame: Because the search terms were revised, ${}^{17}$ search was inception to October 21, 2024

Consensus on Science

Four RCTs $^{31,59-61}$ and 6 observational studies $^{18,19,62-65}$ were identified that compared dispatcher-assisted chest compression-only CPR with conventional CPR at a ra-tio of 15:2 or 30:2 in adults or all ages, with or with-out bystander CPR ongoing at the time of the call. As 15:2 CPR is no longer recommended, all outcomes were downgraded for indirectness. The overall certainty of evi-dence was rated as low to very low for all outcomes, pri-marily due to a very serious risk of bias. Because of this and a high degree of heterogeneity, meta-analyses were not performed. The evidence is summarized in Table 2.

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

|Outcome(certainty of evidence)|Studies(patients)|Results| |---|---|---| |Favorable neurological function (very low-certainty evidence)|1 adult RCT9|No difference compared with 15:2| |Favorable neurological function (very low-certainty evidence)|4 observational studies:1 study included adult bystander-witnessed DA-CPR cases ${}^{82}$; 3 studies examined combined bystander CPR and DA-CPR in adults-witnessed ${}^{19,63}$ and all-age bystander-witnessed ${}^{65}$ cases|2 studies of combined bystander and DA-CPR cases, reported higher odds with CCO-CPR compared with 15:2 (aOR,2.22; 95% CI, 1.17-4.21) ${}^{19}$ or compared with combined 15:2 and 30:2 CPR (aOR,1.12; 95% CI, 1.06-1.19) ${}^{65}$ 2 studies reported no difference compared with 30:2 ${}^{62,63}$| |Survival to hospital discharge or 30 d (very low-certainty evidence)|3 RCTs: 2 in adults, ${}^{59,601}$ in >8 y of age bystander-witnessed ${}^{61}$|No difference in survival to hospital discharge compared with 30:2 ${}^{62,63}$| |Survival to hospital discharge or 30 d (very low-certainty evidence)|5 observational studies:2 in all ages, ${}^{64,65}$ 2 in adults, ${}^{18,62}$ and 1 in adult-witnessed ${}^{63}$|1 reported higher odds with CCO-CPR compared with C-CPR of either 15:2 or 30:2 (aOR,1.05;95% CI,1.01-1.10) ${}^{65}$ 2 reported lower odds with CCO-CPR compared with either 15:2 (aOR,0.69;95% CI,0.53-0.90) ${}^{64}$ or 30:2 CPR (aOR,0.72; 95% CI, 0.59,0.88) ${}^{62}$| |Survival to hospital admission (low-certainty evidence)|4 RCTs: 3 in adults ${}^{31,59,60}$ in 1 >8 y of age bystander-witnessed ${}^{61}$|No difference with DA CCO-CPR compared with either 15:2 ${}^{60,61}$ or 30:2 ${}^{21}$| |ROSC (very low-certainty evidence)|1 all-age observational study ${}^{66}$|No difference compared with either 15:2 or 30:2 CPR|

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

Treatment Recommendations (2025, Unchanged From 2017)

We recommend that dispatchers provide chest compres-sion-only CPR instructions to callers for adults with sus-pected OHCA (strong recommendation, low-certainty evidence).

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A.

In making these recommendations, the task force acknowledged the low-certainty evidence but strongly endorsed the 2020 CoSTR that all rescuers should per-form chest compressions for all patients in cardiac arrest.The task force also considered the following:

● Bystander CPR more than doubles OHCA sur-vival.66 We placed a higher emphasis on the impor-tance of providing high-quality chest compressions and increasing the overall rate of bystander CPR over providing rescue breaths.

● Increases in rates of bystander CPR and patient out-comes have been reported following the introduc-tion of dispatcher-assisted chest compression-only CPR or compression-focused CPR in adults.20,25-27 Using a chest compression-only CPR strategy may increase the willingness of bystanders to respond during a cardiac arrest.

● Most bystander CPR for adults is given with DA-CPR instructions, even in the presence of CPR-trained lay bystanders. ${ }^{31}$

● In making these recommendations, the task force took into consideration heterogeneity in the body

<EndOfPara>of evidence, particularly related to implementation of DA-CPR. Despite this, most included studies suggested either a slight improvement in favor of dispatcher-assisted chest compression-only CPR or no difference in patient outcomes, regardless of patient population or comparison ratio.

Knowledge Gaps

• Studies in children

● The number of chest compressions that should be given, and for how long before ventilation instruc-tions are introduced

● Whether resuscitation instructions should be modi-fied in the context of different causes of arrest (eg,shoking, drowning)

● The impact of prior CPR training

Optimization of Dispatcher-Assisted AED Retrieval and Use(BLS 2120: ScopRev 2024)

A 2024 ScopRev examined the evidence for a new BLS question on interventions to optimize dispatcher-assisted AED and AED retrieval and use for OHCA. The details of this re-view can be found in the ScopRev,69 the 2024 CoSTR summary,40,41 and on the ILCOR website.70

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children with OHCA

● Intervention: Dispatcher-assisted AED retrieval and use

● Outcomes: Any outcomes

● Time frame: All years to April 13,2023

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Treatment Recommendations (2024)

EMS implementing dispatcher-assisted public access AED systems should monitor and evaluate the effective-ness of their system (good practice statement).

Once a cardiac arrest is recognized during the emer-gency call and CPR has been started, dispatchers should ask if there is an AED(or defibrillator) immediately avail-able at the scene and ask the caller to update them when one arrives (good practice statement).

If an AED is not immediately available and if there is more than 1 rescuer present, dispatchers should offer instructions to locate and retrieve an AED. Retrieval instructions should be supported, where resources allow,by up-to-date registries about public access AED loca-tions and accessibility (good practice statement).

Once an AED is available, dispatchers should offer instructions on its use (good practice statement).

Drone Delivery of AEDs (BLS 2122: ScopRev 2023; EvUp 2025)

A ScopRev for 2023 and a 2025 EvUp examined the evidence on drone delivery of AEDs. The details of this review can be found in the ScopRev,71 the 2023 CoSTR summary,67 and on the ILCOR website.72 The 2025 EvUp is provided in Appendix B.

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in OHCA

• Intervention: Drone-delivered AEDs

● Comparators: Standard EMS response times (or time for EMS-delivered AED), AEDs delivered by bystanders (or activated volunteer responders)

● Outcomes: Real-world/estimated feasibility, time gain of drone-delivered AEDs(compared with stan-dard EMS delivery), predicted survival, predicted quality-adjusted life years gained, cost-effectiveness,and calculated proportion of defibrillation and sur-vival compared with cases where AEDs are brought to the OHCA scene by standard means

● Time frame: December 1,2022, to August 6,2024

Summary of Evidence

The EvUp identified 11 additional studies. ${ }^{73-83}$ The new evidence does not warrant a new SysRev. There is no existing treatment recommendation on this topic, and the current evidence does not support a new one.

AED Accessibility(Locked Cabinets)(BLS 2123: ScopRev 2025)

Rationale for Review

Rapid defibrillation is critical to improving patient out-comes because each minute of delay in attempting defibrillation reduces the chances of survival and good

functional outcomes.84-86 Concerns about theft, vandal-ism, and misuse of AEDs have led to the use of security measures, including locked cabinets, to house these devices in public areas.87-89 Given the lack of a compre-hensive review of this approach, this topic was prioritized for review by the BLS Task Force. The full details of this review can be found in the ScopRev$90 and on the ILCOR website. ${ }^{91}$

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in out-of-hospital settings

● Concept: The benefits and harms of placing AEDs in locked cabinets versus unlocked cabinets

● Context: Any locations where an AED is placed with the intention of the AED being publicly accessible for use

• Outcomes: Any outcome, including AED outcomes(eg,AED use, time to AED use, AED vandalism or theft)

● Time frame: All years to June 25,2024

Summary of Evidence

Ten reports were included: 7 observational studies re-porting rates of theft and vandalism,92-1001 survey re-porting on harm to rescuers,101 and 2 AED retrieval simulation studies.92,93 Four studies were reported as conference abstracts97-100 and 2 were letters to the editor.94,96

No study reported on the impact of locked AED cabi-nets on patient outcomes. Most studies reported low rates(<2%) of theft, missing AEDs, or vandalism and this occurred in locked and unlocked cabinets.92-100 The only study, comparing unlocked and locked cabinets showed minimal difference in theft and vandalism rates(0.3% versus 0.1%).99 Two simulation studies showed significantly slower AED retrieval when additional secu-rity measures, including locked cabinets, were used.9293 A survey of first responders reported half (n=25/50) were injured in accessing an AED that required breaking glass to access.101

Task Force Insights

An evidence-to-decision button is provided in Appendix A.

● While acknowledging that most of the data identi-fied has not undergone peer review and there may be publication bias, reported rates of AED theft and vandalism were low across all studies, and thefts occurred in both locked and unlocked cabinets.AEDs reported as stolen may have been used in an emergency and not returned.

● To ensure EMS is activated for OHCAs, some sys-tems use cabinets locked with a code obtained by calling EMS. ${ }^{102}$ However, this may cause delays,particularly if a telephone is not readily available,and its impact requires further study. ${ }^{103}$

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● The cost to replace stolen or vandalized AEDs may be a challenge in low-resource settings(eg,com-munity groups with limited funding).

● We agree with the 2022 ILCOR scientific state-ment, which focuses on optimizing PAD and advises against using locked cabinets. ${ }^{104,105}$ If locked cabi-nets are used, instructions for unlocking them need to be clear and ensure no delays in access.

Treatment Recommendations

We advise against using locked cabinets for public ac-cess defibrator storage (good practice statement).

If locked cabinets are used for public access defibril-lator storage, instructions for unlocking them must be clear and ensure minimal delays in access (good practice statement).

EMS should devise strategies to return public access defibrillators when used (good practice statement).

Knowledge Gaps

● Peer-reviewed research and human studies on this topic, particularly studies focusing on real-life retrieval and the impact of security strategies on delivery times and patient outcomes

BLS SEQUENCE

Starting CPR(CAB Versus ABC) in Adults(BLS 2201, SysRev 2025)

Rationale for Review

This was a nodal review with BLS and the Pediatric Life Support(PLS) Task Forces. The existing ILCOR treatment recommendation was last updated in 2020. 37,38 This topic was prioritized for a detailed nodal review because only EvUps had been done since 2020. The pediatric CoSTR,treatment recommendations, and evidence-to-decision table are reported on the ILCOR website $^{106}$ and in the PLS CoSTR section. $^{107}$ The SysRev was registered on PROSPERO (CRD42024583890), and the full CoSTR can be found on the ILCOR website. $^{106}$

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in any setting(in-hospital or out-of-hospital) with cardiac arrest

● Intervention: Commencing CPR with compressions first(30:2)

● Comparator: Commencing CPR with ventilations first(2:30)

• Outcomes:

- Critical: Survival with favorable neurological out- come at hospital discharge or 30 days, survival at hospital discharge or 30 days, survival with favor-able neurological outcome to 1 year, survival to 1 year, event survival, any ROSC

- Important: Time to commencement of rescue breaths, time to commencement of first compres-sion, time to completion of first CPR cycle, venti-lation rate, compression rate, chest compression fraction, minute ventilation

• Time frame: Because the search terms were revised,the search included all years to June 18, 2024

Consensus on Science

One new pediatric manikin simulation study110 (pub-lished with corrections$^{1111$ ) in addition to the 4 manikin simulation studies$^{112-115}$ found in the previous ILCOR re-views $^{37,38,116,117}$ were identified. Of the 5 manikin studies,3 were randomized studies (1 in adult114 and 2 in pediat-ric resuscitation $^{110,113}$ ), and 2 were observational studies in adult resuscitation. $^{12,115}$

No human studies were identified. Evidence was very low certainty for all outcomes, downgraded for very seri-ous risk of bias and indirectness. Because of this and a high degree of heterogeneity, no meta-analyses could be performed, and individual studies are difficult to interpret.This evidence from the manikin studies is summarized in Table 3.

Prior Treatment Recommendations (2020)

We suggest commencing CPR with compressions rather than ventilations (weak recommendation, very low-cer-tainty evidence).

Treatment Recommendations (2025)

The 2025 treatment recommendation in adults is un-changed from 2020. The pediatric treatment recommen-dation is reported in the PLS CoSTR section.${}^{107}$

In adults in cardiac arrest, we suggest commencing CPR with compressions rather than ventilations(weak recommendation, very low-certainty evidence).

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A.

Please see the PLS section for evidence-to-decision highlights for children. In making these rec-ommendations for adults, the task forces considered the following:

Most of the existing evidence, all of very low certainty,suggests the following:

● Starting CPR with compressions first results in improvements in key elements of resuscitation,such as commencement of chest compressions,completion of the first cycle of compressions, and a higher chest compression fraction.

● Indirect evidence from before-and-after OHCA reg-istry studies in adults suggests that switching from the ABC to CAB approach was associated with increased rates of bystander CPR25 and improved

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

|Outcome(certainty of evidence)|Studies(participants)|Results for cardiac arrest scenarios| |---|---|---| |Time to commencement of chest compressions (very low)|1 crossover pediatric manikin RCT (159 two-person teams)113 1 adult manikin RCT (108 two-person teams)114|CAB sequence resulted in faster mean time to chest compressions: 19.3±2.6 versus 43.4±5.0 s(P<0.05)113;25±9 versus 43±16 s(P<0.001)114| ||2 adult manikin observational studies (33 six-person teams12;40 single rescuers115)|CAB sequence was associated with shorter time to chest compressions: median =16.0 (IQR = 14.0-26.0) versus 42.0 (IQR = 41.5-59.0) s(P<0.001)112; and mean = 15.4±3.0 versus 36.0±4.1 s(P<0.001)115| |Time to commencement of rescue breaths/ventilations (very low)|1 crossover pediatric manikin RCT (159 two-person teams)113 1 adult manikin RCT (108 two-person teams)114|CAB sequence resulted in later mean times to commencement of ventilation: 28.4 ±3.1 versus 22.7±3.1 s(P<0.05)113;43±10 versus 37±15 s(P<0.001)114 In the respiratory arrest scenario, CAB sequence resulted in faster mean time to commencement of ventilation: 19.1±1.5 versus 22.7±0.1 s(P<0.05)113| |Time to completion of first CPR (30 chest compressions and 2 rescue breaths) (very low)|1 adult manikin RCT (108 two-person teams)114|CAB sequence resulted in shorter mean times to completion of the first resuscitation cycle (30:2):48±10 versus 63±17 s(P<0.001)| |Ventilation rate (very low)|1 crossover pediatric manikin RCT10(28 two-person teams)|In a sequence of delivering 5 rescue breaths before commencing chest compressions, ABC resulted in more ventilations delivered in the first minute of resuscitation: median 13 (IQR = 12-15) versus 10 (IQR = 8-10;P<0.05)| |Compression rate (very low)|1 crossover pediatric manikin RCT110 (28 two-person teams)|No difference in compression rate| |Compression rate (very low)|1 adult manikin observational study teams (33 six-person teams)112|No difference in median compression depth| |CChip (very low)|1 crossover pediatric manikin RCT110 (28 two-person teams)|No difference in compression depth| |CChip (very low)|1 adult manikin observational study teams (33 six-person teams)112|No difference in compression depth| |CCF (very low)|1 crossover pediatric manikin RCT110 (28 two-person teams)|In a sequence of delivering 5 rescue breaths before commencing chest compressions, ABC resulted in lower median CCF 57%(IQR = 54-64) versus 66%(IQR = 59-68; P<0.001)| |CCF (very low)|1 adult manikin observational study team (33 six-person teams)112|No difference in CCF| |Minute alveolar ventilation in the first minute of resuscitation (very low)|1 crossover pediatric manikin RCT110 (28 two-person teams)|In a sequence of delivering 5 rescue breaths before commencing chest compressions, minute alveolar ventilation in the first min of resuscitation was higher with ABC: median 370 mL (IQR = 203-472) versus 276 mL (IQR = 140-360; P<0.001)|

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

patient outcomes.25,118,119 Similar data on in-hospital cardiac arrest show conflicting evidence in patient outcomes.120,121

● While important uncertainties remain, in retaining this treatment recommendation in adults, the BLS task force also considered the following:

- The benefits of a single training approach in adults

- Effective chest compressions generate cumula-tive coronary perfusion pressure, which falls to near zero when compressions stop. Therefore,early effective chest compressions are vital to establishing and maintaining coronary perfusion pressure.122

- Time to first compression is associated with bet-ter patient outcomes. ${}^{123}$

- Bystanders are typically unable to deliver effec-tive ventilations during simulated CPR.35

- Due to the public's concerns with mouth-to-mouth ventilation,32 commencing CPR with air-way and ventilations may result in no bystander CPR being provided.

- Evidence suggests that delivering the ABC approach leads to more errors in CPR, ${}^{113}$ that lay-bystanders prefer CAB, and that CAB is easier to learn and retain. ${}^{113}$

The delivery of non-mouth-to-mouth ventilation requires the retrieval and preparation of equip-ment(eg, bag-mask device, pocket mask), which,when multiple rescuers are present, can occur during chest compressions.

Knowledge Gaps

No human studies directly evaluate this question in any setting. Because different councils worldwide have adopted CAB versus ABC, comparative studies

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of different registries may provide evidence to answer this question.

Chest Compression-to-Ventilation Ratios (BLS 2202: SysRev 2025)

Rationale for Review

This was a nodal review with BLS and the PLS Task Forces. The previous SysRev13 and existing ILCOR treat-ment recommendation was first published in 2017.14,15 This topic was prioritized for a detailed review because it had not been reviewed since 2017. The SysRev was registered on PROSPERO (CRD42024559318), and the full CoSTR can be found on the ILCOR website. ${ }^{124}$

Population, Intervention, Comparator, Outcome,Study Design, and Time Frame

● Population: Adults and children in-hospital with car-diac arrest

● Intervention: Any CPR ratio delivered by EMS

● Comparators: Eligible comparator groups include a CPR ratio different from the one in the interven-tion arm delivered by EMS. Comparator groups that received no CPR or compared manual CPR with mechanical CPR were excluded from the review.Studies including automated CPR or any use of mechanical devices will only be included if adminis-tered to all treatment arms.

• Outcomes:

- Critical: Favorable neurological survival (as mea-sured by CPC or mRS) at discharge or 30 days and at any time interval after 30 days

- Important: Survival to discharge or 30 days, sur-vival to hospital admission, survival to any time interval after discharge or 30-day survival, ROSC,quality of life as measured by any indicator or score

● Study design: In addition to standard criteria, obser-vational studies that reported only unadjusted data were excluded.

● Time frame: Because the search terms were revised,the search included all years to October 21,2024

Consensus on Science

Eight studies examined the impact of the 2005 resus-citation guidelines, in which changes to compression-to-ventilation (CV) ratios were made in combination with other bundled interventions. ${ }^{119,125-131}$ The studies consisted of 7 retrospective cohort studies, ${ }^{119,125-130}$ and one prospective study. ${ }^{131}$ No study included children. Evi-dence was very low-certainty in all cases.

For the critical outcome of favorable neurological sur-vival at discharge or 30 days, we identified 2 cohort stud-ies. ${ }^{126,131}$ In 1 cohort study of 3960 initially nonshockable OHCA, ${ }^{126}$ implementation of the 2005 resuscitation guidelines (including a CV ratio of 30:2) was associated with an improvement in neurologically favorable survival

at hospital discharge (CPC score 1-2) compared with a prior period using a CV ratio of 15:2 (odds ratio [OR],1.56; 95% CI, 1.11, 2.18). In another cohort study of 522 initially shockable OHCA, ${ }^{131}$ being treated under the 2005 guidelines was associated with no change in neu-rologically favorable survival at 30 days (CPC score 1-2)compared with being treated with a CV ratio of 15:2 (OR,0.50; 95% CI, 0.20, 1.25).

For the critical outcome of survival to hospital dis-charge or 30-day survival, we identified 6 cohort studies. ${ }^{119,125-128,130}$ Because of heterogeneity, no meta-analysis was performed.

• CV ratio 30:2 versus 15:2: In 3 studies of OHCA with all rhythms, a CV ratio of 30:2 compared with 15:2 was associated with higher odds of survival in 2 studies(adjusted OR[aOR], 1.8;95% CI, 1.2,2.7128;aOR,2.5;95% CI,1.4,4.6)127 but not in the third study(aOR,1.42;95% CI,0.79,2.57).125 For OHCA with initially shockable rhythm, 1 study reported higher odds of survival to hospital discharge with a CV ratio of 30:2 compared with 15:2(aOR, 1.62;95% CI, 1.33-1.98), which became nonsignificant after adjustment for the temporal trend(aOR, 1.07;95% CI, 0.71, 1.62).130 In OHCA patients with ini-tial nonshockable rhythm, a CV ratio of 30:2 com-pared with 15:2 was associated with higher odds of survival in one study(aOR 1.53; 95% CI, 1.14,2.05).126 but not in the other(aOR 1.19; 95% CI,0.82,1.73).130

· CV ratio 50:2 versus 5:1: A before-after study of 200 bystander-witnessed OHCA with initial shock-able rhythms reported an improvement in survival to hospital discharge following the implementation of a bundled change in resuscitation practice consisting of a CV ratio of 50:2 compared with 5:1(aOR,2.17;95% CI,1.26-3.73).${}^{119}$

For the critical outcome of ROSC, one cohort study of 1243 OHCA patients found no change in the risk-adjusted odds of ROSC with a CV ratio of 30:2 com-pared with 15:2(OR,1.31;95% CI,0.99,1.73). ${ }^{129}$

Treatment Recommendations (2025, Unchanged From 2017)

We suggest a compression-ventilation ratio of 30:2 compared with any other compression-ventilation ratio in adult patients in cardiac arrest (weak recommendation,very low-certainty evidence).

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A.

In making this recommendation, the task force placed a high priority on consistency with our prior treatment recommendations and the findings identified in this review, which suggest that the bundle of care, which included changing to a CV ratio of 30:2, resulted in more

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lives being saved. The task force also considered the following:

● All studies included in this review suffered from serious indirectness, where a change to CV ratio was delivered or introduced as part of a bundle of care that included other changes, such as increases in the duration of CPR cycles, removal of stacked shocks, removal of postshock rhythm checks and fewer interruptions to chest compressions. It is pos-sible that the benefits observed in these studies are not related to a change in CV ratio.

● Future studies and reviews should focus on the benefit of higher CV ratios, compared with the cur-rent recommendation of 30:2.

Knowledge Gaps

● The impact of different ratios without any other con-current changes in practice

● The benefit of higher CV ratios compared with 30:2

● The ability of those providing CPR to deliver 2 effective ventilations during the short pause in chest compressions during CPR

● Examination of the ratio-dependent tidal volume required to maintain oxygenation

Duration of CPR Cycles (BLS 2212: SysRev 2025)

Rationale for Review

This topic was last reviewed in detail132 for the 2020 CoSTR,3738 and was prioritized for a detailed review because only EvUps had been done since 2020. The full CoSTR can be found on the ILCOR website.133 Because there was no intent to publish this review outside of the 2025 CoSTR,PROSPERO registration was not completed.

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in any setting(in-hospital or out-of-hospital) with cardiac arrest.

● Intervention: Pausing chest compressions at another interval

● Comparators: Pausing chest compressions every 2 minutes to assess the cardiac rhythm

• Outcomes:

- Critical: Survival with favorable neurological out-come at hospital discharge or 30 days; survival at hospital discharge or 30 days

-Important: ROSC; coronary perfusion pressure,cardiac output

● Time frame: September 1,2019,to September 22,2024

Consensus on Science

No new clinical studies have been identified since the 2020 ILCOR SysRev.37,38 The existing evidence consists of 2 RCTs(Table 4). ${}^{134,135}$

Treatment Recommendations (2025, Unchanged From 2015)

We suggest pausing chest compressions every $2~min$ -utes to assess the cardiac rhythm (weak recommenda-tion, low-certainty evidence).

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is included in Appendix A.

These included trials were designed to address the question of CPR or defibrillation first and provide only indirect evidence for different CPR cycle durations.

In making the suggestion to pause chest compres-sions every 2 minutes to assess cardiac rhythm, we placed a high value on being consistent with previous recommendations in the absence of any convincing evidence indicating potential benefit from changing to CPR cycles of a different duration. The BLS Task Force acknowledges that every guideline change comes with significant risk and costs.

Knowledge Gaps

● Whether the optimal CPR interval between rhythm analyses differs between initial cardiac rhythms

● The impact of no-flow and low-flow time

● The impact of stopping CPR on the overriding goal of minimizing interruptions in chest compressions

● The relationship between rescuenormal, between rescuer fatigue, chest compression quality and the optimal interval for chest compression cycles, and whether this relation-ship varies based on the number of rescuers present

EMS Continuous-Chest Compression CPR vs Conventional CPR (BLS 2221: SysRev 2025)

Rationale for Review

The previous SysRev ${}^{13}$ and existing ILCOR treatment recommendation were first published in 2017.14,15 This topic was prioritized for a detailed review because it had not been reviewed since 2017. The SysRev was regis-tered on PROSPERO (CRD42024559318), and the full CoSTR can be found on the ILCOR website. ${ }^{136}$

Population, Intervention, Comparator, Outcome,Study Design, and Time Frame

● Population: Adults and children with out-of-hospital with cardiac arrest

● Intervention: Continuous chest compressions with or without ventilations delivered by EMS

● Comparators: Standard CPR, defined as any CV ratio delivered by EMS. Comparator groups that receive no CPR or compared manual CPR with mechani-cal CPR were excluded from the review. Studies including automated CPR or any use of mechani-cal devices were only included if administered to all treatment arms.

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Table 4.Evidence Comparing Duration of CPR Cycles

|Study(design)|Participants(intervention)|Outcomes: RR(95% CI)|Certainty of evidence| |---|---|---|---| |3 min versus 1 min|3 min versus 1 min|3 min versus 1 min|3 min versus 1 min| |Wik 2003 $^{134}$ (RCT)|200 adult OHCAs 3 min (intervention): immediate defibrillation(up to 3 stacked shocks) for VF/VT followed by 3 min of CPR for regardless of postshock rhythm 1 min (comparator): immediate defibrillation(up to 3 stacked shocks) for VF/VT followed by 1 min of CPR for patients in refractory VF/VT, and 3 min of CPR for patients who were in nonshockable rhythms following initial 1-3 shocks|Compared with 1 min, there was no difference for 3-min duration: Survival to hospital discharge with favorable neurological outcome (absolute RR,1.68;95% CI,0.85-3.32;P=0.13) Survival to hospital discharge (absolute RR,1.52;95% CI,0.83-2.77;P=0.17) ROSC (absolute RR,1.22;95% CI,0.92-1.50;P=0.16)|Very low (downgraded for risk of bias and imprecision)| |1 min versus 2 min|1 min versus 2 min|1 min versus 2 min|1 min versus 2 min| |Baker 2008 $^{135}$|202 adult OHCAs 1 min (intervention): stacked shocks (up to 3 in refractory VF/VT), 15:2 CPR and 1-min CPR cycles between defibrillation 2 min (comparator): single shock, 30:2 CPR and 2-min CPR cycles between defibrillation|Compared with 2 min, there was no difference for 1-min duration: Survival to hospital discharge (RR,0.49;95% CI,0.23- 1.06;P=0.06) ROSC(RR,0.95;95% CI,0.73-1.24; P=0.71)|Very low (downgraded for risk of bias and imprecision)|

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

• Outcomes:

- Critical: Favorable neurological survival(as mea-sured by CPC or mRS) at discharge or 30 days and at any time interval after 30 days

-Important: Survival to discharge or 30 days, sur-vival to hospital admission, survival to any time interval after discharge or 30 days survival,ROSC, quality of life as measured by any indica-tor or score

● Study design: In addition to standard criteria, obser-vational studies that reported only unadjusted data were excluded.

● Time frame: Because the search terms were revised,the search included all years to October 2024

Consensus on Science

We identified 1 cluster crossover RCT137 and 3 cohort studies, ${}^{138-140}$ including 2 post hoc analyses of the ear-lier cluster RCT, providing low to moderate certainty of evidence(downgraded for indirectness and risk of bias).The evidence is summarized in Table 5.

Prior Treatment Recommendations(2019)

We recommend that EMS providers perform CPR with 30 compressions to 2 breaths(30:2 ratio) or con-tinuous chest compressions with positive-pressure ventilation(PPV) delivered without pausing chest compressions until a tracheal tube or supraglottic de-vice has been placed(strong recommendation, high-certainty evidence).

We suggest that, when EMS systems have adopted minimally interrupted cardiac resuscitation, this strategy is a reasonable alternative to conventional CPR for wit-nessed shockable OHCA(weak recommendation, very low-certainty evidence).

Treatment Recommendations(2025)

During basic life support for adults in cardiac arrest,we recommend that EMS personnel use either a 30:2 CV ratio or continuous chest compressions with PPV(10/min) delivered without pausing compressions(strong recommendation, moderate-certainty evidence).

Justification and Evidence-to-Decision Framework

The complete evidence-to-decision table is provided in Appendix A.

The task force noted no high-certainty evidence to support the superiority of either continuous chest com-pressions or standard CPR for patient outcomes in OHCA and placed a high value on the importance of pro-viding high-quality chest compressions and simplifying resuscitation logistics for EMS personnel.

Changes made to the wording of the treatment rec-ommendation were based on several factors. First, the existing wording was open to misinterpretation. Second,highest-quality evidence is a cluster RCT that compared a 30:2 ratio to ventralations at a rate of 10/min without pausing compressions across the first 3 resuscitation cycles(ie, 6 minutes of BLS resuscitation). After this time point, the study arms both switched to the same advanced life support(ALS) protocol, including the placement of an advanced airway and ventilations at a rate of 10/min without pausing compressions. Third, a growing body of evidence suggests that ventilation rates vary widely in both synchronous and asynchronous venti-lations.141 Additionally, substudies of the included cluster crossover RCT137 suggest that a CV ratio of 30:2 may be harder to achieve in practice and could result in a higher degree of nonadherence compared with continuous chest compressions ${}^{140}$ ; but when performed correctly, it

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

|Outcome(certainty of evidence)|Studies(patients)|Results| |---|---|---| |Favorable neurological function (moderate)|1 adult cluster RCT37147 randomized to either CCC with asynchronous PPV or standard CPR with a CV ratio of 30:2|No difference compared with 30:2| |Survival to hospital discharge or 30 d (low to moderate)|1 adult cluster RCT371|No difference compared with 30:2| |Survival to hospital discharge or 30 d (low to moderate)|3 observational studies: 1 compared minimally interrupted cardiac resuscitation with C-CPR (including a CV ratio of 15:2, stacked shocks, and postshock rhythm checks) ${}^{138}$; 1 post hoc analysis of the Nichol cluster RCT197 was restricted to sites in British Columbia ${}^{139}$; 1 secondary analysis of patients enrolled into the ROC registry or either the ROC CCC, ALPS, or PART clinical trials were classified CCC with asynchronous ventilations or C-CPR (30:2)140|Minimally interrupted cardiac resuscitation was associated with improved survival to hospital discharge (aOR, 3.0; 95% CI, 1.1-8.9). ${}^{138}$ A post hoc analysis of the Nichol cluster RCT ${}^{137}$ reported no significant difference in survival to hospital discharge. ${}^{139}$ The secondary analysis showed that CCC was associated with improved survival to hospital discharge when compared with standard CPR (aOR, 1.20; 95% CI, 1.04, 1.38). Further analysis showed when there was adherence to the intended strategy, CCC had significantly lower survival (aOR, 0.72; 95% CI, 0.64, 0.81), while in patients with the intended strategy, 30:2 had higher survival (aOR, 1.05; 95% CI, 0.90, 1.22).140| |ROSC (low to moderate)|1 adult cluster RCT137|No difference compared with 30:2| ||1 cohort study compared minimally interrupted cardiac resuscitation C-CPR (including a CV ratio of 15:2, stacked shocks, and postshock rhythm checks). ${}^{138}$|No difference compared with 15:2|

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

may be associated with improved outcomes compared to compressions with asynchronous ventilations140 and incorrect performance of 30:2.142

The task force removed the 2017 recommendation supporting systems that have implemented minimally interrupted cardiac resuscitation(ie, 200 compressions without ventilations) for witnessed shockable OHCA.This decision was made because the former recommendation was supported by a single retrospective study reporting adjusted estimates for the intervention,138 with a serious risk of bias from uncontrolled confounding because the study implemented a bundle including other resuscitation practices. The task force also considered the following:

● Interruptions in chest compressions have been associated with poorer clinical outcomes in obser-vational studies.143 Pauses for ventilations are a significant source of interruptions in chest compres-sions and may negatively impact coronary and actic blood flow.144 Asynchronous PPV(continuous chest compressions with PPV delivered without pausing chest compressions) may achieve similar oxygen-ation without compromising chest compression quality.

● Although there was relative homogeneity in the con-tinuous chest compressions strategies, there was heterogeneity in the use of ventilation strategies,including both asynchronous PPV and passive oxy-genation(delivering oxygen during compressions without providing ventilation). The adequacy of ven-tilation was not assessed in any studies, although measures of chest compression quality(eg, chest compression fraction) were reported.

Knowledge Gaps

● The effect of delaying PPV during CPR

● The impact of different elements of minimally inter-rupted cardiac resuscitation(compressions, ventila-tion, delayed defibrillation) on patient outcomes

● The impact of adherence to continuous chest com-pressions or a CV ratio of 30:2 on patient outcomes

In-Hospital Continuous-Chest Compression CPR vs Conventional CPR(BLS 2222: SysRev 2025)

Rationale for Review

This was a nodal review with BLS and the PLS Task Forces.The previous SysRev13 and existing ILCOR treat-ment recommendation was first published in 2017.14.15 This topic was prioritized for a detailed review as it had not been reviewed since 2017. The SysRev was regis-tered on PROSPERO(CRD42024559318), and the full CoSTR can be found on the ILCOR website. ${}^{145}$

Population, Intervention, Comparator, Outcome,Study Design, and Time Frame

• Population: Adults and children in-hospital with car-diac arrest

• Intervention: Continuous chest compressions with or without ventilations delivered by in-hospital providers.

• Comparators: Standard CPR, defined as any CV ratio delivered by in-hospital providers. Comparator groups that received no CPR or compared manual

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CPR with mechanical CPR were excluded from the review. Studies including automated CPR or any use of mechanical devices were only included if administered to all treatment arms.

• Outcomes:

- Critical: Favorable neurological survival (as mea-sured by CPC or mRS) at discharge or 30 days and at any time interval after 30 days

- Important: Survival to discharge or 30 days, sur-vival to hospital admission, survival to any time interval after discharge or 30 days survival,ROSC, quality of life as measured by any indica-tor or score

● Study design: In addition to standard criteria, obser-vational studies that reported only unadjusted data were also excluded.

● Time frame: Because the search terms were revised,the search included all years to October 21,2024

Consensus on Science

No new studies were identified. One single-center cohort study included in the previous review provided very low-certainty evidence(downgraded for risk of bias and very serious imprecision).146 The study evaluated the effect of continuous mechanical chest compressions in adult pa-tients admitted to an emergency department following OHCA. PPV without interruption of chest compressions after tracheal intubation was compared with interruption of chest compressions for one ventilation after every fifth chest compression(a CV ratio of 5:1) among patients ad-mitted to a hospital emergency department after OHCA.

No adjusted data were reported for favorable neuro-logical survival at discharge or 30 days. For the critical out-come of survival, patients who received tracheal intubation with PPV during continuous compressions had increased adjusted survival to hospital discharge (aOR, 2.43; 95%CI, 1.15-5.12) and higher odds of ROSC (aOR, 1.62;95%CI, 1.07-2.43) when compared with those who received mechanical chest compressions interrupted for ventilations at a ratio of 5 compressions to 1 ventilation.

Prior Treatment Recommendation (2019)

Whenever tracheal intubation or a supraglotatic airway is achieved during in-hospital CPR, we suggest that providers perform continuous compressions with PPV delivered without pausing chest compressions(weak recommendation, very low-quality evidence).

Treatment Recommendations (2025)

In adults in cardiac arrest, in-hospital personnel should use either a 30:2 CV ratio or continuous chest compres-sions with PPV(10/min) delivered without pausing com-pressions (good practice statement).

Justification and Evidence-to-Decision Framework Highlights

<BeginOfPara>The complete evidence-to-decision Table is provided in Appendix A.

In changing the recommendation to a good practice statement, the task force acknowledges the lack of evi-dence of this topic and no studies in children. The good practice statement removed reference to the advanced airway to fill the treatment gap and provide guidance for immediate CPR. The task force also considered the following:

● Interruptions in chest compressions have been associated with worse clinical outcomes in obser-vational studies. ${}^{143}$ Pauses for ventilations are a significant source of interruptions in chest compres-sions and may negatively impact coronary and aortic blood flow. ${}^{144}$ PV during chest compressions may achieve similar oxygenation without compromising chest compression quality.

● The only included study was conducted with a before-and-after design that, although adjusted for demographic and cardiac arrest characteristics, did not account for potential temporal differences in resuscitation efficiencies between study periods.

● Data on the same question in EMS found no high-quality evidence to support the superiority of either continuous chest compressions or standard CPR for patient outcomes in OHCA.

● The task force also placed a relatively high value on providing high-quality chest compressions and sim-plifying resuscitation logistics for clinicians.

● Substudies of the included cluster crossover $RCT^{137}$ suggest that a CV ratio of 30:2 may be harder to achieve in practice and could result in a higher degree of nonadherence compared with continuous chest compressions $^{140}$ ; but when performed correctly, 30:2 may be associated with improved outcomes com-pared to compressions with asynchronous ventila-tions $^{140}$ and incorrect performance of 30:2.$^{142}$

Knowledge Gaps

● Effectiveness of continuous chest compressions with or without ventilations compared with standard CPR with a CV ratio, when delivered by in-hospital personnel

● The effect of delaying PPV during CPR

● The effectiveness of passive oxygenation during resuscitation

● The impact of adherence to chest compression-only CPR or a CV ratio of 30:2 on patient outcomes

● Evidence in pediatric patients

BLS COMPONENTS-COMPRESSIONS

Hand Position During Compressions(BLS 2502: SysRev 2025)

Rationale for Review

Hand positioning during compressions was last reviewed in detail for the 2020 CoSTR.3738 Since 2020, EvUps

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have identified evidence only from imaging studies. Be-cause these studies contribute new indirect evidence,this topic was prioritized for review. The full CoSTR can be found on the ILCOR website. ${ }^{147}$ Because there was no intent to publish this review outside of the 2025 CoSTR,PROSPERO registration was not completed.

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest

• Intervention: Any other location for chest compressions

• Comparators: Delivery of chest compressions on the lower half of the sternum

• Outcomes: Any clinical outcome

- Critical: Survival to hospital discharge with good neurological outcome; survival to hospital discharge

- Important: ROSC; blood pressure; coronary per-fusion pressure; end-tidal carbon dioxide

• Time frame: October 1, 2019, to September 26,2024

Consensus on Science

No studies reported the critical outcomes of favor-able neurological outcome, survival, or ROSC. No new clinical studies have been identified since the 2020 ILCOR SysRev.37,38 The existing evidence consists of 3 very low-certainty studies reporting on physiologic endpoints.148-150 One crossover study in 17 adults with prolonged resuscitation from nontraumatic cardiac ar-rest observed improved peak arterial pressure during compressions and higher end-tidal carbon dioxide when compressions were performed on the lower third of the sternum compared with the center of the chest, whereas arterial pressure during compression recoil, peak right atrial pressure, and coronary perfusion pressure did not differ.150 A second crossover study in 30 adults observed no association between end-tidal carbon dioxide values and hand placement.149 A further crossover study in 10 children observed higher peak systolic pressure and higher mean arterial blood pressure when compressions were performed over the lower third of the sternum com-pared with the middle of the sternum.148

Treatment Recommendations (2025, Unchanged From 2015)

We suggest performing chest compressions on the lower half of the sternum on adults in cardiac arrest (weak rec-ommendation, very low-certainty evidence).

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A.

<BeginOfPara>No studies evaluated the effect of a specific hand position on short- or long-term survival after cardiac

arrest, and only physiologic surrogate outcomes were evaluated.

Imaging studies were excluded from the current SysRev because they do not report clinical outcomes for cardiac arrest patients. However, they provide valu-able indirect information. Recent studies indicate that,in most adults and children, the maximal ventricular cross-sectional area is located beneath the lower third of the sternum or the xiphisternal junction. Additionally,the ascending aorta and left ventricular outflow tract are positioned beneath the center of the chest.151-157 The studies also highlight significant anatomical differences between individuals based on factors such as age, body mass index, congenital cardiac disease, and pregnancy.Consequently, no single hand-placement strategy may be universally optimal for chest compressions across all populations.154,156,158,159

In reaffirming the recommendation to perform chest compressions on the lower half of the sternum, we priori-tized consistency with previous guidelines given the lack of compelling clinical evidence necessitating a change in approach.

Knowledge Gaps

● The effects of different hand positions during CPR on patient outcomes

● How to determine the optimal hand placement or compression point for individuals in cardiac arrest,particularly by leveraging physiologic feedback or incorporating insights from prior imaging

Head-Up CPR(BLS 2503: SysRev 2025)

Rationale for Review

This was a nodal review with BLS and the ALS Task Forces. The first SysRev with treatment recommen-dations for head-up CPR was published in the 2021 CoSTR.160,161 Since 2021, the topic has been reviewed in EvUps, which identified new observational studies, and the SysRev was therefore updated for 2025. The SysRev was registered on PROSPERO (CRD42024541714),the full details of this review can be found in the SysRev,162 and the full CoSTR can be found on the ILCOR website.163

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in any setting(in-hospital or out-of-hospital) with cardiac arrest

● Intervention: Head-up CPR or head-up CPR bundle(eg, head-up position, active compression/decom-pression, and an impedance threshold device)

● Comparators: Standard or chest compression-only CPR in supine position

• Outcomes:

- Critical outcomes: Survival to hospital discharge with good neurological outcome, survival to

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hospital discharge, event survival, survival to 30 days, survival to 30 days with good neurological outcome

-Important outcome: ROSC

● Time frame: July 22,2021,to July 19,2024

Consensus on Science

Two new observational studies were identified, adding to the single study identified in 2021.164-166 All studies were from the same research group. Details of study designs and key findings are presented in Table 6. Evidence was deemed very low-certainty for all outcomes because of serious risk of bias, inconsistency, and imprecision.

Prior Treatment Recommendations(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 head-up CPR dur-ing CPR be assessed in clinical trials or research initiatives(weak recommendation, very low-certainty evidence).

Treatment Recommendations(2025)

We suggest against the use of head-up CPR or head-up CPR bundle during CPR except in the setting of clinical trials or research initiatives(weak recommendation, very low-certainty evidence).

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A.

In making this recommendation, the BLS Task Force recognized that the currently available evidence remains limited, highlighted by the absence of RCTs or observational studies with adequate comparisons. The comparator groups used in all 3 available studies are problematic(eg, earlier time frame), and some out-comes are reported without adjustment for known con-founders or temporal trends. The implementation of the existing head-up CPR bundles requires the purchase of expensive equipment, which includes an automated head/thorax-up positioning device, a mechanical CPR

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

|Study|Design (time frame), participants,intervention, comparator|Outcomes|Certainty of evidence| |---|---|---|---| |Pepe|Before-after study,2014-2017: 2322 adult OHCAs (1356 intervention)|Survival to hospital discharge with favorable neurological outcome: Unadjusted 35% to 40% intact neurological status in both groups (exact data and loss to follow-up not provided)|All outcomes: very low-certainty evidence (downgraded for risk of bias,inconsistency,and imprecision)| |Intervention: Head-up CPR bundle that included mechanical CPR and ITD; oxygen but deferred PPV for several minutes; a pit-crew approach for rapid placement of the mechanical CPR device; and subsequent placement of patient in a reverse Trendelenburg position(≈20)|Event survival: Unadjusted 17.9%(n= 144/806) versus 34.2%(n=464/1356),P<0.001|Event survival: Unadjusted 17.9%(n= 144/806) versus 34.2%(n=464/1356),P<0.001|| |Moore 2022165|Prospective observational: Automated Controlled Elevation CPR Registry,2019-2020: 5423 adult OHCAs (227 intervention) Intervention: Automated controlled head and thorax patient positioning device. Immediate elevation of head and mithorox at 12 cm and 8 cm, respectively, with conventional CPR for 2 min; followed by a gradual elevation of patient's head and torso during CPR over an additional 2-min period to a final head and thorax elevation of 22 cm and 9 cm, respectively. Comparator: Conventional CPR with supine position(data from 3 RCTs conducted between 2006 and 2015167-109)|After propensity matching: Survival to hospital discharge with favorable neurological outcome: 5.9%(13/222) versus 4.1%(35/860); OR, 1.47 (95% CI, 0.76-2.82) Survival to hospital discharge: 9.5%(21/122) versus 6.7% (58/860);OR,1.44 (95% CI,0.86-2.44) ROSC:33% (74/222) versus 33%(282/860); OR,1.02 (95% CI,0.75-1.49)|Certainty of evidence| |Bashista 2024164|Prospective observational: Automated Head/Thorax-UP Positioning Registry(2019-2021): 2232 adult nonshockable OHCAs (380 intervention) Intervention: Automated controlled head and thorax patient positioning device, immediate elevation of head and mithorox at 12 cm and 8 cm, respectively, with conventional CPR for 2 min; followed by a gradual elevation of patient's head and torso during CPR over an additional 2-min period to a final head and thorax elevation of 22 cm and 9 cm, respectively. Comparator: Conventional CPR with supine position (data from 3 RCTs conducted between 2006 and 2015167-109)|After propensity matching: Survival to hospital discharge with favorable neurological outcome: 4.2%(15/353) versus 1.1%(4/353); OR,3.87 Survival to hospital discharge: 76%(27/353) versus 2.8%(10/353); OR,2.84 (95% CI,1.35-5.96) ROSC:33%(118/353) versus 29%(101/353); OR,1.25 (95% CI,0.91-1.72)|Certainty of evidence| |Bashista 2024164|Prospective observational: Automated Head/Thorax-UP Positioning Registry (2019-2021): 2232 adult nonshockable OHCAs (380 intervention) Intervention: Automated controlled head and thorax patient positioning device, immediate elevation of head and mithorox at 12 cm and 8 cm, respectively, with conventional CPR for 2 min; followed by a gradual elevation of patient's head and torso during CPR over an additional 2-min period to a final head and thorax elevation of 22 cm and 9 cm, respectively. Comparator: Conventional CPR with supine position (data from 2 RCTs conducted between 2006 and 2009167,189)|After propensity matching: Survival to hospital discharge with favorable neurological outcome: 4.2%(15/353) versus 1.1%(4/353); OR,3.87 Survival to hospital discharge: 76%(27/353) versus 2.8%(10/353); OR,2.84 (95% CI,1.35-5.96) ROSC:33%(118/353) versus 29%(101/353); OR,1.25 (95% CI,0.91-1.72)|Certainty of evidence|

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

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device, and an impedance threshold device, as well as considerable training.

Although the intervention may sound simple, the included studies demonstrate the complexities. We did not find clini-cal evidence supporting a particular bundle approach or indicating that the sole use of head-up elevation is superior to other bundles without it. There is an indication that faster deployment of head-up CPR is associated with better neu-rological outcomes, ${}^{165}$ but this requires further study.

Knowledge Gaps

• High-quality evidence of the effect of head-up CPR or head-up CPR bundle is required.

● The optimal approach(eg, the angle and timing of head elevation) when head-up CPR is used

Minimizing Pauses in Compressions(BLS 2504: SysRev 2022, EvUp 2025)

A 2022 SysRev and 2025 EvUp examined the evidence on passive ventilation techniques. The details of the 2022 SysRev review can be found in the 2022 CoSTR summary$^{170,171}$ and on the ILCOR website.$^{172}$ The 2025 EvUp is provided in Appendix B.

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults in cardiac arrest in any setting

● Intervention: Minimizing pauses in chest compres-sions (higher CPR or chest compression fraction or shorter perishock pauses compared with control)

● Comparator: Standard CPR(lower CPR fraction or longer perishch pauses compared with intervention)

• Outcomes:

- Critical: Survival to hospital discharge with good neurological outcome; survival to hospital discharge

-Important:ROSC

● Time frame: June 1,2021,to April 14,2024

Summary of Evidence

The EvUp found 1 new study ${}^{173}$ directly relevant to the population, intervention, comparator, outcome, study de-sign, and time frame and several studies with meaning-ful data on interruptions in cardiac arrest care. 140,173-176 However, these later studies were excluded because they did not address the prespecified outcomes of inter-est. This suggests a SysRev might be warranted in the future after revising the population, intervention, com-parator, outcome, study design, and time frame question.

Treatment Recommendations (2022)

We suggest that CPR fraction and perishock pauses in clinical practice be monitored as part of a comprehensive quality improvement program for cardiac arrest designed to ensure high-quality CPR delivery and resuscitation care across resuscitation systems (weak recommenda-tion, very low-certainty evidence).

We suggest that preschock and postshock pauses in chest compressions be as short as possible (weak rec-ommendation, very low-certainty evidence).

We suggest that the CPR fraction during cardiac arrest(CPR time devoted to compressions) should be as high as possible and be at least 60%(weak recom-mendation, very low-certainty evidence).

Optimal Surface for Performing CPR (BLS 2510: SysRev 2024)

A 2024 SysRev updated the 2019 review177 on the op-timal surface for performing CPR. The full details of this review can be found in the SysRev, ${}^{178}$ the 2024 CoSTR summary, ${}^{40,41}$ and on the ILCOR website. ${}^{179}$

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults or children in cardiac arrest(OHCA and in-hospital cardiac arrest)

• Intervention: The performance of CPR using a hard surface (eg, backboard, floor, or deflatable or spe-cialist mattress)

● Comparators: The performance of CPR on a regular mattress or other soft surface

• Outcomes:

- Critical: Survival with a favorable neurological out-come at hospital discharge/30 days; survival at hospital discharge/30 days

-Important: Event survival; ROSC; CPR quality (eg,compression depth, compression rate, compres-sion fraction)

● Time frame: September 17, 2019, to February 5,2024.

Treatment Recommendations (2024)

We suggest performing chest compressions on a firm surface when possible (weak recommendation, very low-certainty evidence).

During in-hospital cardiac arrest, we suggest, where a bed has a CPR mode, which increases mattress stiff-ness, it should be activated(weak recommendation, very low-certainty evidence).

During in-hospital cardiac arrest, we suggest against moving a patient from a bed to floor to improve chest compression depth(weak recommendation, very low-certainty evidence).

During in-hospital cardiac arrest, we suggest in favor of either a backboard or no-backboard strategy, to improve chest compression depth (conditional recom-mendation, very low-certainty evidence).

Feedback for CPR Quality (BLS 2511: ScopRev 2024)

A 2024 ScopRev examined the wider literature on feedback for CPR quality during resuscitation. The

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details of this review can be found in the ScopRev,${}^{180}$ the 2024 CoSTR summary, ${}^{40,41}$ and on the ILCOR website. ${}^{181}$

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children(excluding neo-nates) who are in cardiac arrest in any setting who are resuscitated by health professionals responding in a professional capacity

● Intervention: Real-time feedback and prompt devices regarding the mechanics of CPR qual-ity (eg, rate and depth of compressions or ventilations)

● Comparators: No feedback or prompt devices or alternative devices

● Outcomes: Any outcomes or measure of CPR quality

● Time frame: All years to July 18, 2023. A gray lit-erature search was performed in the Google search engine in addition to the standard databases.

Treatment Recommendations (2020)

We suggest the use of real-time audiovisual feedback and prompt devices during CPR in clinical practice as part of a comprehensive quality improvement program for cardiac arrest designed to ensure high-quality CPR delivery and resuscitation care across resuscitation systems (weak recommendation, very low-certainty evidence).

We suggest against the use of real-time audiovisual feedback and prompt devices in isolation (ie, not part of a comprehensive quality improvement program) (weak recommendation, very low-certainty evidence).

BLS COMPONENTS-VENTILATION

Passive Ventilation Techniques(BLS 2403:SysRev 2022, EvUp 2025)

<BeginOfPara>A 2022 SysRev and 2025 EvUp examined the evidence on passive ventilation techniques. The details of this re-view can be found in the 2022 CoSTR summary170,171 and on the ILCOR website. ${ }^{182}$ The 2025 EvUp is pro-vided in Appendix B.

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children with presumed car-diac arrest in any setting

● Intervention: Any passive ventilation technique (eg,positioning the body, opening the airway, passive oxygen administration, Boussignac tube, constant flow insufflation of oxygen) in addition to chest compressions

● Comparator: Standard CPR

· Outcomes:

- Critical: Survival to hospital discharge with good neurological outcome; survival to hospital discharge

-Important: ROSC

• Time frame: October 16, 2021, to July 5, 2024

Summary of Evidence

No new studies were identified, so a new SysRev is not warranted.

Treatment Recommendations (2022)

We suggest against the routine use of passive ventilation techniques during conventional CPR (weak recommen-dation, very low-certainity evidence).

Real-Time Ventilation Quality Feedback Devices (BLS 2402: ScopRev 2025)

Rationale for Review

A growing body of evidence suggests ventilation param-eters during resuscitation often fall outside guideline rec-ommendations. ${ }^{183,184}$ This review was prioritized because new devices are now available to help BLS personnel monitor and improve ventilation in real time. Ventilation parameters were not addressed in detail in our recent review of real-time feedback. ${ }^{180}$ The full details of this review can be found in the ScopRev ${ }^{185}$ and on the ILCOR website. ${ }^{186}$

Population, Intervention, Comparator, Outcome,Study Design, and Time Frame

● Population: Adults of children in any setting (out-of-hospital or in-hospital) in cardiac arrest

● Intervention: Real-time ventilation quality feedback(eg, tidal volume, adequate ventilation, mask leak, ventilation rate)

● Comparators: No real-time ventilation feedback

• Outcomes: Any outcome

• Study designs: In addition to standard study designs,gray literature (Google Scholar, first 20 pages), let-ters to the editor, and conference abstracts were eligible for inclusion.

● Time frame: Inception to September 11, 2024. The gray literature was searched on November 4, 2024.

Summary of Evidence

The ScopRev $^{185}$ identified 19 relevant studies (1 RCT,$^{187}$1 before-after prospective study,188 2 observational studies,190,191 1 case series,192 and 12 simulation stud-ies193-2002-205). Three of the simulation studies assessed pediatric scenarios.197,203,205

One RCT $^{187}$ and 1 prospective observational study $^{188}$ examined clinical outcomes with and with-out real-time feedback (Table 7). The RCT reported improved immediate-term patient outcomes with real-time feedback but no change in short-term outcomes.

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

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

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

The trial did not adjust for group differences or report ventilation quality.187 The observational study found no change in patient outcomes but noted improved venti-lation parameters with real-time feedback.188 Most of the simulation studies showed improvements in venti-lation quality.

Treatment Recommendations (2025)

There is currently insufficient evidence on real-time ven-tilation quality feedback devices to make a treatment recommendation.

Task Force Insights

The task force discussed the review findings and noted the following:

● Device registration with regulatory authorities alone does not provide evidence of device performance in real-world settings. As rescuer and patient fac-tors influence high-quality ventilation, the current evidence is insufficient to demonstrate the clinical efficacy or effectiveness of real-time ventilation feedback devices.

● The lack of studies in humans, the significant hetero-geneity between studies, and industry involvement in 7 included studies are all important limitations of the evidence.

● Many of the included studies inaccurately labeled inflation volume, the amount of airflow measured at the mask, or the advanced airway as tidal vol-ume. We suggest using inspiratory volume rather than tidal volume for this measurement, because tidal volume represents the amount of air that moves in or out of the lungs with each respiratory cycle.

Based on this ScopRev, at this time there is insuffi-cient evidence to pursue a new SysRev on this topic.

Knowledge Gaps

● High-quality prospective evidence in humans,including changes to ventilation variables and con-ducted independent of industry, that assess the clin-ical efficacy(ie, whether the devices work in optimal settings) or clinical effectiveness(real-world set-tings) of these devices

• Data in children

BLS COMPONENTS-DEFIBRILLATION

Pad/Paddle Size and Placement in Adults(BLS 2601: SysRev 2025)

Rationale for Review

This was a nodal review with BLS, PLS, and the ALS Task Forces.The existing ILCOR treatment recommendation was first published in 2010206,207 and reviewed in a ScopRev for the 2020 CoSTR.3738 Publications found in EvUps and the publication of a cluster RCT208 on pad placement prompted a nodal SysRev209 with the BLS, PLS, and ALS Task Forces(PROSPERO registration CRD42024512443).The pedi-atric CoSTR, treatment recommendations, and evidence-to-decision table are reported on the ILCOR website210 and in the PLS CoSTR section.107 The CoSTR can be found on the ILCOR website.211

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in any setting(in-hospital or out-of-hospital) with cardiac arrest and a shockable rhythm at any time during CPR

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● Intervention: The use of any specific pad size/orien-tation and position

● Comparators: Reference standard pad size/orienta-tion and position

• Outcomes:

- Critical: Survival with favorable neurological out-come at hospital discharge or 30 days; survival at hospital discharge or 30 days

-Important: ROSC; termination of ventricular fibril-lation(VF); rates of fibrillation

● Time frame: All years to September 22,2024

Consensus on Science

Two observational studies $^{212,213}$ and 1 RCT ${}^{208}$ were iden-tified. Certainty of evidence was very low in all cases.

Pad Size

No studies compared the effects of different pad sizes with standard size for any critical outcomes or ROSC.One before-and-after study in OHCA reported no differ-ence in defibrillation success with AEDs with large pad size(113 cm ${ }^{2}$ ), compared with AEDs with small pad size(65 ${ }^{2}$ cm²) (86% versus 88.8\%; OR, 0.82; 95% CI, 0.42-1.60). ${ }^{212}$ No studies were identified in the in-hospital setting.

Pad Positions

No RCTs were found that compared different pad place-ments for the initial defibrillation.

One prospective EMS cohort study^{213} adjusting for known predictors found no significant difference in favor-able neurological outcome at hospital discharge with ini-tial anterior-posterior(AP) pad placement compared with initial anterior-lateral(AL) placement(aOR, 1.86; 95%CI, 0.98-3.51). There was also no difference in survival to hospital discharge(aOR, 1.55; 95% CI, 0.83-2.90)or in defibrillation success (VF termination at 5-second postshock: OR, 1.08; 95% CI, 0.61-1.91), although AP pad position was associated with higher ROSC rates after adjusting for known predictors(aOR, 2.64; 95% CI,1.50-4.65).

Pad Positions for Refractory VF

One cluster RCT, which was stopped early because of the COVID-19 pandemic, compared vector-change defi-brillation (a change to the AP position) with continuation of the standard AL position in 280 adult OHCA patients with refractory VF (ie, persistence of VF or pulseless ventricular tachycardia after 3 consecutive AL defibril-lations). ${ }^{208}$ This RCT reported higher adjusted survival to hospital discharge with vector change to AP pad posi-tion (21.7% versus 13.3%; adjusted risk ratio, 1.71; 95%CI, 1.01-2.88), but no difference in favorable neurologi-cal outcome at hospital discharge, (aOR, 1.86; 95% CI,0.98-3.51).

<BeginOfPara>The same RCT reported higher rates of termination of VF with vector change to AP pad position (79.9% versus

67.6%; adjusted risk ratio, 1.18; 95% CI, 1.03-1.36) but no difference in ROSC(35.4% versus 26.5%; adjusted risk ratio, 1.39; 95% CI, 0.97-1.99).

No studies were identified in the in-hospital setting.

Prior Treatment Recommendations(2010)

It is reasonable to place pads on the exposed chest in an AL position. An acceptable alternative position is AP. In large-breased individuals, it is reasonable to place the left electrode pad lateral to or underneath the left breast, avoiding breast tissue. Consideration should be given to the rapid removal of excessive chest hair before the ap-plication of pads, but emphasis must be on minimizing delay in shock delivery.

There is insufficient evidence to recommend a spe-cific electrode size for optimal external defibrillation in adults. However, it is reasonable to use a pad size greater than 8 cm.

Treatment Recommendations (2025)

For Defibrillator Manufacturers

There is insufficient evidence to recommend a specific pad or paddle size for optimal external defibrillation in adults (good practice statement).

Manufacturers should standardize adult pad or paddle placement in the AL position (good practice statement).One pad or paddle should be placed below the right clav-icle, just to the right of the upper sternal border, and the other with its center in the left midaxillary line, below the armpit.

Manufacturers should provide clear instructions to ensure proper contact between the pad or paddle and the skin, along with diagrams that accurately show the ILCOR-recommended pad and paddle positions (good practice statement).

For AED Users

Follow the manufacturer's AED guidance and instruc-tions for adult pad placement(good practice statement).

For Health Care Professionals Trained in Manual Defibrillation

In adults, place defibrillator pads or paddles in the AL position to optimize placement speed and minimize in-terruptions to chest compressions(good practice state-ment). One pad/paddle should be positioned below the patient's right clavicle, just to the right of the upper ster-nal border. The other pad/paddle should be placed on the patient's left paddixillary line, below the armpit.

In adults, if the initial AL position is not feasible, con-sider using the AP pad position if trained (good practice statement). Place the anterior pad on the left side of the chest, between the midline and the nipple. For female patients, place the anterior pad to the left of the lower sternum, ensuring it avoids breast tissue as much as pos-sible. The posterior pad should be placed on the left side of the patient's spine, just below the scapula.

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Pad or paddle placement should avoid breast tissue(good practice statement).

For Health Care Professionals Trained in Vector Change For adults in refractory VF (persistent VF after 3 defibril-lations), consider changing pads to the AP pad position (good practice statement). Place the anterior pad on the left side of the chest, between the midline of the chest and the nipple. For female patients, place the anterior pad to the left of the lower sternum, ensuring it avoids breast tissue as much as possible. The posterior pad should be placed on the left side of the patient's spine,just below the scapula. This treatment recommendation does not replace the existing treatment recommendation on vector change and double sequential defibrillation for ALS clinicians.67

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A.

The pediatric treatment recommendations are reported in the PLS CoSTR section.107 In making these recommendations for adults, the task forces considered the following:

● All included studies were at serious risk of bias.No study reported patient outcomes for pad size,and no study compared the effects of different pad placements on patient outcomes except when being used for refractory shockable rhythms. However,defibrillator manufacturers may have proprietary data, and we encourage manufacturers to make this data public.

● In the absence of in-hospital cardiac arrest studies,this evidence could be applied to in-hospital cardiac arrest, with additional downgrading for indirectness.

● Lower transthoracic impedance results in higher current flow, possibly enabling higher defibrillation success. Observational studies in adults showed that transthoracic impedance was significantly higher with small-sized pads/paddles compared with large-sized pads/paddles. ${}^{212,214,215}$

● A secondary analysis of the Double Sequential External Defibrillation for Refractory Ventricular Fibrillation trial ${}^{216}$ explored the relationship between vector change to AP placement and the type of VF(shock-refractory or recurrent) on patient outcomes.The study reported that vector change to AP place-ment, compared with continuation of AL position-ing, was not superior for VF termination,ROSC, or survival for shock-refractory VF. For recurrent VF,vector-change defibrillation was superior for VF ter-mination, but not for ROSC or survival.

● Paddles may still be in use in some low-resource ALS settings. However, the Task Force acknowl-edges that the AP position is not feasible with

paddles and that paddle sizes are standard as provided by the manufacturer. The task force did not foresee future development in the use of paddles.

● AEDs have diagrams to guide users in correct pad positioning. However, there is wide variation in these diagrams, and evidence suggests that untrained bystanders fail to achieve accurate pad placement when guided by current defibrillation pad diagrams.217

Knowledge Gaps

● The impact of different pad positions in the first 3 shocks on patient outcomes

● The effect of different pad sizes on patient outcomes

● Optimal pad sizes and positions in children and in-hospital settings

● The interaction between pad size and orientation

Removal of Bra for Pad Placement and Defibrillation (BLS 2604, ScopRev 2025)

Rationale for Review

The BLS Task Force prioritized this review because the topic is controversial and, to date, no comprehensive review has been undertaken. The full details of this re-view can be found in the ScopRev ${}^{218}$ and on the ILCOR website ${}^{219}$

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults: Adults and children in cardiac arrest

● Concept: Adverse events and outcomes associated with pad placement or defibrillation without remov-ing the patient's bra/brassiere (including those with metal components)

● Context: In patients wearing a bra/brassiere in any setting (in-hospital or out-of-hospital)

● Time frame: All years to September 26, 2024; gray literature searched (Google Scholar, first 200 refer-ences) October 1, 2024.

Summary of Evidence

No studies reporting patient outcomes were identified.One animal study220 and 2 simulation manikin stud-ies221,222 were included. The evidence is summarized in Table 8.

Task Force Insights

The evidence-to-decision table is included in Appendix A. The task force discussed the review findings and not-ed the following:

● Two included studies were published as conference abstracts by the same group of authors who were employed by a company that develops and manu-factures AEDs.56 A growing body of research has

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

|Study details|Study design (publication type)|Intervention|Key findings| |---|---|---|---| |Di Maio 2015^{220}|Porcine model (n= 4 ) with induction of arrhythmia and defibrillation by an AED Conference abstract|AED pads in direct contact with the metal wires of a bra placed on the pig Induction of VF and defibrillation with 200 J shocks|No scorching or burning of the bra or skin Poor pad placement did not pose a risk to the operator (risk type not specified) No arcing No redirection of the current 100% first shock success (no instances of fibrillation)| |Kramer 2015^{221}|69 randomly assigned undergraduate students: Simulation of OHCA with CPR and AED on male or female mankins (use of a wig, makeup, silicone breasts, front- opening brassiere, color-coordinated women's clothing) Peer-reviewed article|Voice prompt AED guidance on opening the case, activating AED, positioning of pads, shock delivery,administering CPR|Female manikins less likely to be completely disrobed than the male manikins (42.4% versus 91.7%, P<0.001) Male rescuers less likely to completely disrobe the female manikins than female rescuers were (13.3% versus 66.7%, P= 0.002) Opinions on removal of clothes: Thought they needed only to remove enough clothing to place the defibrillator pads according to instructions rather than ensuring the brassiere would not affect CPR Social norms Concerned for patient modesty Men did not want to remove more clothing than necessary| |O'Hare 2014^{222}|78 randomly selected untrained AED users: Simulation of resuscitation with AED use on manikins as either “female” (clothed in a front-opening hooded sweater with a bra) or “male” (no bra) Conference abstract|Removal of clothes (including bra) from the manikin guided by the AED voice prompt|No difference in time to place electrodes: 52 versus 49 s for female versus male manikin, respectively No difference in time to first shock: 79.5 versus 77 s for female versus male manikin, respectively 88.5% of the participants correctly placed the electrodes and delivered a shock (sex of manikin not specified)|

AED indicates automated external defibrillator; CPR, cardiopulmonary resuscitation; OHCA, out-of-hospital cardiac arrest; and VF, ventricular fibrillation.

identified that women are less likely to receive CPR and defibrillation by the public. ${}^{223-225}$ Public opinion surveys show that some members of the public do not feel comfortable exposing women's breasts, and fear accusations of inappropriate touching and sex-ual assault.226 These concerns may impact bystand-ers' willingness to perform CPR and defibrillation and explain why rates are lower in women. Whether it is necessary to remove such undergarments is unknown.

● This ScopRev demonstrated scant evidence on this topic. Peer review occurred for only 2 of the 3 included studies. We found no evidence report-ing patient outcomes or any case studies reporting adverse events from defibrillation without removing a bra.

● Leaving the bra on could result in inaccurate pad placement, but routine removal could compromise timely defibrillation, particularly in bystander situa-tions. Some AED's verbal and written instructions do not describe bra removal, so the public may not currently remove it to place pads.

● There are likely to be privacy and cultural issues associated with fully exposing a woman's chest.Some resuscitation groups are already actively training to keep the bra on to overcome hesitancy in bystanders. However, correct and timely pad place-ment must be a priority.

● Although insufficient studies were identified to sup-port a more specific SysRev of defibrillation while wearing a bra at this time, the task force felt the need to highlight and address the inequality in AED appli-cation in women by making good practice statements to highlight this issue to the international community.

Treatment Recommendations(2025)

There is insufficient evidence to guide the routine remov-al of a bra, but it may not always be necessary to remove a bra for defibrillation. Pads must be placed on bare skin in the correct position, which may be possible by adjust-ing the bra's position rather than removing it(good prac-tice statement).

Manufacturers should develop realistic manikins that reflect different body sizes that can impact pad place-ment(good practice statement).

Where possible, CPR training should cover defibrilla-tion for patients wearing bras, focusing on correct pad placement and minimizing pauses in compressions(good practice statement).

Knowledge Gaps

● Whether removing a bra is necessary with modern bras, pads, and defibrillators

● Sex-specific barriers to high-quality CPR and defi-brillation; listening to emergency calls may provide critical insights to address in public messaging and CPR training

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● A better understanding of public opinions and socio-cultural sensitivities related to exposing the chest

Effectiveness of Ultraportable AEDs (BLS 2603:ScopRev 2024)

A 2024 ScopRev examined the evidence on the effec-tiveness of ultraportable AEDs. The details of this review can be found in the ScopRev,227 the 2024 CoSTR sum-mary,40,41 and on the ILCOR website.228

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in OHCA

● Intervention: the use of an ultraportable or pocket AED

• Outcomes: all outcomes were accepted

● Time frame: 2012 to October 31, 2023. We did not search gray literature.

Treatment Recommendations (2024)

There is currently insufficient evidence on the clinical ef-fectiveness of ultraportable or pocket AEDs to make a treatment recommendation.

SPECIAL CIRCUMSTANCES

OHCA Following Drowning

A 2021 ScopRev,2023 SysRev, and 2025 EvUps ex-amined the evidence on 7 drowning questions. For these questions the population and outcomes are the same across all subtopics, and interventions and comparators are detailed for each subtopic. The details of this review can be found in the ScopRev,229 SysRev,230 the 2023 CoSTR summary,67 and on the ILCOR website.231-235 The 2025 EvUps are provided in Appendix B.

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in cardiac arrest fol-lowing drowning

• Outcomes:

- Critical: Survival to discharge or 30 days with favorable neurological outcome; survival to dis-charge or 30 days

-Important:ROSC

● Time frame: April 25, 2023, to April 14, 2024

Immediate Resuscitation in Water or on Boat in Drowning (BLS 2702/2703: ScopRev 2021,SysRev 2023, EvUp 2025)

Intervention and Comparator

● Intervention: Immediate resuscitation in water or on boat

● Comparator: Delaying resuscitation until on land

Summary of Evidence

The EvUp identified no new studies. A SysRev is not warranted.

Treatment Recommendations (2023)

We suggest 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 on-boat CPR may be delivered if res-cuers trained in this technique determine that it is fea-sible 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 res-cuers may delay resuscitation until on land (good prac-tice statement).

CAB Versus ABC in Drowning (BLS 2704:ScopRev 2023, SysRev 2024, EvUp 2025)

A slight change to the 2023 treatment recommendation was made to align with the treatment recommendations for all cardiac arrest patients.

Intervention and Comparator

● Intervention: Resuscitation that incorporates a compression-first strategy (ABC)

● Comparator: Resuscitation that starts with ventila-tion(ABC)

Consensus on Science

No studies were identified that addressed the popula-tion, intervention, comparator, outcome, study design, and time frame question in the SysRev or the EvUp.

Prior Treatment Recommendations(2023)

We recommend a compression-first strategy (CAB) for laypeople providing resuscitation for adults and children in cardiac arrest caused by drowning (good practice statement).

We recommend health care professionals and those with a duty to respond to drowning(eg, lifeguards) con-sider providing rescue breaths/ventilation first (ABC)before chest compressions if they have been trained to do so (good practice statement).

Treatment Recommendations (2025)

We recommend a compression-first strategy (CAB) for laypeople providing resuscitation for adults in cardiac ar-rest caused by drowning (good practice statement).

Health care professionals and those trained and with a duty to respond to drowning(eg, lifeguards)should consider providing rescue breaths/ventilation first (ABC) before chest compressions (good practice statement).

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Justification and Evidence-to-Decision Framework Highlights

There is no evidence-to-decision table because no evi-dence was identified. In making the good practice state-ments, the task force considered the following:

● The compression-first strategy for adults prioritizes simplicity and cohesiveness in training recom-mendations for laypersons, with the goal of faster initiation of resuscitation. We also considered the indirect manikin studies $^{110,112-115}$ published in the review of this question for all cardiac arrests (BLS 2202).

● The ventilation-first strategy for health care profes-sionals and those with a duty to respond consid-ers that indirect evidence from a study examining in-water ventilations may improve outcomes ${}^{236}$ and the specialized training of lifeguards and health care professionals (including cardiac monitoring and ventilation-delivery equipment). It is unclear if earlier ventilations improve outcomes once cardiac arrest has occurred or if the benefit is in preventing respiratory arrest from deteriorating into cardiac arrest.

Of note, no direct or indirect evidence is available to support any certain number of initial ventilations if life-guards or health care professionals adopt a ventilation-first strategy. Most importantly, resuscitation should not be delayed by either selected strategy.

Knowledge Gaps

There were no studies that directly evaluated this ques-tion. Further research, informed by the Utstein tem-plate for drowning, may usefully address this ongoing uncertainty.

Chest Compression-Only CPR in Cardiac Arrest in Drowning(BLS 2705: ScopRev 2023, SysRev 2023, EvUp 2025)

Intervention and Comparator

• Intervention: Chest compression-only CPR

● Comparator: Conventional CPR (compressions and ventilations)

Summary of Evidence

The EvUp identified no new studies. No SysRev is warranted.

Treatment Recommendations (2023)

For lay responders, the treatment recommenda-tions for CPR in drowned OHCA patients who have been removed from the water remain consistent with CPR for all patients in cardiac arrest (good practice statement).

Adults: We recommend that bystanders perform chest compressions for all patients in cardiac arrest.

We suggest that bystanders who are trained, able, and willing to give rescue breaths and chest compressions do so for adults in cardiac arrest.

Children: We suggest that bystanders provide CPR with ventilation for infants and children younger than 18 years with OHCA.

We recommend that if bystanders cannot provide rescue breaths as part of CPR for infants and children younger than 18 years with OHCA, they should at least provide chest compressions.

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).

Ventilation Equipment in Cardiac Arrest

Following Drowning (BLS 2706: ScopRev 2023,SysRev 2023, EvUp 2025)

Intervention and Comparator

● Intervention: Ventilation with equipment before hos-pital arrival

● Comparator: Ventilation without equipment before hospital arrival

Summary of Evidence

The EvUp identified no new studies. No SysRev is warranted.

Treatment Recommendations (2023)

We recommend using mouth-to-mouth, mouth-to-nose,or pocket-mask ventilation by BLS providers and layeo-ple for adults and children in cardiac arrest caused by drowning(good practice statement).

We suggest that bag-mask ventilation can be used by lifeguards or other BLS providers with a duty to respond, on the condition that it is part of a competency-based training program with regular retraining and maintenance of equipment (good prac-tice statement).

We recommend that health care professionals follow the ALS treatment recommendations for airway manage-ment for adults and children in cardiac arrest caused by drowning.

Prehospital Oxygen Administration Following Drowning(BLS 2707: SysRev 2023, EvUp 2025)

Intervention and Comparator

● Intervention: Oxygen administration before hospital arrival

● Comparator: No oxygen administration before hos-pital arrival

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Summary of Evidence

The EvUp identified no new studies. No SysRev is warranted.

Treatment Recommendations (2023)

When available, we recommend trained providers use the highest possible inspired oxygen concentration dur-ing resuscitation for adults and children in cardiac arrest following drowning (good practice statement).

AED Use First Versus CPR First in Cardiac Arrest in Drowning (BLS 2708: ScopRev 2023, SysRev 2023, EvUp 2025)

Intervention and Comparator

● Intervention: AED administered before CPR

● Comparator: CPR administered before AED

Summary of Evidence

The EvUp identified no new studies. No SysRev is warranted.

Treatment Recommendations (2023)

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 is used in cardiac arrest caused by drowning in adults and children(good practice statement).

PAD Programs for Drowning(BLS 2709: SysRev 2023, EvUp 2025)

Intervention and Comparator

● Intervention: PAD program

● Comparator: Absence of PAD program

Summary of Evidence

The EvUp identified no new studies. No SysRev is warranted.

Treatment Recommendations (2023)

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).

CPR During Transport (BLS 2715: SysRev 2022, EvUp 2025)

A 2022 SysRev and 2025 EvUp examined the evidence on CPR during transport. The details of this SysRev can be found in the 2022 CoSTR summary ${}^{170,171}$ and on the ILCOR website. ${}^{237}$ The 2025 EvUp is provided in Appendix B.

Population, Intervention, Comparator, Outcome, and Time Frame

• Population: Adults and children receiving CPR fol-lowing OHCA

• Intervention: Transport with ongoing CPR

● Comparator: Completing CPR on scene(until ROSC or termination of resuscitation)

• Outcomes:

- Critical: Survival to hospital discharge with good neurological outcome; survival to hospital discharge

-Important: Quality of CPR metrics on scene ver-sus during transport (reported outcomes may include rate of chest compressions, depth of chest compressions, chest compression fraction, interruptions to chest compressions, leaning on chest/incomplete release, rate of ventilation, vol-ume of ventilation, duration of ventilation, pres-sure of ventilation); ROSC

● Time frame: November 2020 to April 22,2024

Summary of Evidence

The EvUp identified several studies, ${ }^{238-247}$ including a pro-tocol $^{248}$ and early results in abstract form ${ }^{249}$ for a recently completed but not yet fully published RCT. This SysRev will be updated following the publication of the RCT.

Treatment Recommendations (2022)

We suggest that providers deliver resuscitation at the scene rather than undertake ambulance transport with ongoing resuscitation unless there is an appropriate indi-cation to justify transport (eg, extracorporeal membrane oxygenation) (weak recommendation, very low-certainty evidence).

The quality of manual CPR may be reduced during transport. We recommend that whenever transport is indicated, EMS providers should focus on the delivery of high-quality CPR throughout transport(strong recom-mendation, very low-certainty evidence).

Delivery of manual CPR during transport increases the risk of injury to providers. We recommend that EMS systems have a responsibility to assess this risk and,where practicable, to implement measures to mitigate the risk (good practice statement).

CPR in Obese Patients (BLS 2720, ScopRev 2025)

Rationale for Review

This topic was prioritized for review by the BLS, the ALS,the PLS, and the Education, Implementation, and Teams Task Forces because of the increasing prevalence of obe-sity worldwide and the specific challenges in providing CPR to this patient cohort. This topic has not previously been reviewed by ILCOR. The full details of this review can be found in the ScopRev ${ }^{250}$ and on the ILCOR website. ${ }^{251}$

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Basic Life Support: CoSTR 2025

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest

• Intervention: CPR(including mechanical and e-CPR) in obese patients(as defined in specific papers)

● Comparators: May have no comparator, comparator of nonobese patients, or compare modified CPR for obese patients with standard CPR

• Outcomes:

- Critical: Survival to hospital discharge with good neurological outcome; survival to hospital discharge

-Important: ROSC; CPR quality measures (chest compression rate, chest compression depth,ventilation rate, tidal volume, end-tidal carbon dioxide), CPR timing (time to commencement of rescue breaths, first compression, first defi-brillation if shockable rhythm); CPR techniques(chest compressions, defibrillation, ventila-tion and airway management, vascular access and medications); health-related quality of life and CPR provider outcomes (safety, manual handling)

● Time frame: All years to October 1,2024

Summary of Evidence

Thirty-six studies were included.252-287 Definitions of obe-sity varied. Full reporting of the results can be found in the ScopRev.250

In adults, the association between obesity and neurological outcomes, survival to hospital discharge, longer-term survival (months to years), and ROSC was variable. In children, worse neurological outcomes, lower survival, and lower ROSC than normal-weight children were reported in 2 studies. Few studies reported resus-citation quality indicators, and no studies reported on adjustments to CPR techniques or outcomes for those providing CPR.

Task Force Insights

The task force discussed the review findings and noted the following:

● At the time of this review, there was no universal definition of obesity, so for the purposes of this ScopRev, obese was defined according to each indi-vidual study.There was wide variability in the defini-tions of obesity across the studies.

● In adults, the evidence of the impact of obesity on patient outcomes was conflicting.

● ln children, 2 studies suggested that obese chil-dren had worse neurological outcomes, lower survival, and lower ROSC than normal-weight children.

● The variability in results does not suggest an urgent need to deviate from standard CPR protocols. Some evidence suggests CPR duration may be longer in obese adults, which may have staffing and resource implications.

Treatment Recommendations

Standard CPR protocols should be used in obese pa-tients(good practice statement).

Knowledge Gaps

● Few studies of CPR in obese infants, children, and adolescents

● A standardized definition of obese, or population-specific definition of obese, for the purpose of resuscitation research

● The true impact of obesity on CPR outcomes when other factors are accounted for

● The effect of obesity on CPR techniques (such as chest compressions, airway management and ven-tilation, and defibrillation), CPR quality, and time to and delivery of resuscitation interventions (such as vascular access and medications, use of mechanical CPR, devices or extracorporeal membrane oxygen-ation) in both adults and children

● Whether the degree of obesity influences CPR performance, outcomes following CPR(including health-related quality of life), or inclusion in CPR research

● The effect of patient obesity on outcomes of those providing CPR (eg, physical exertion, manual han-dling, fatigue)

Topics Not Included in the 2025 Review

● PAD programs(BLS 2121)

● CPR prior to defibrillation (BLS 2203)

● Check for circulation during BLS(BLS 2210)

● Timing of rhythm check (BLS 2211)

● Chest compression rate, depth, recoil (BLS 2501)

Topics Retired or Reposed

● Resuer fatigue in chest compression-only CPR

● CPR before call, for help

● Alternative compression techniques(cough,precor-dial thump, fist pacing)

Topics Moved to the First Aid Task Force

● Harm from CPR to victims not in arrest

● Foreign-body airway obstruction

● Resuscitation care for suspected opioid-associated emergencies

● Drowning factors related to survival

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ARTICLE INFORMATION

The American Heart Association requests that this document be cited as follows:Bray JE, Smyth MA, Perkins GD, Cash RE, Chung SP, Considine J,Nad- sanayake V,Debaty G,Dewan M,Dicker B,Dodge N,Folke F,Ikeyama T,Hansen CM,Johnson NJ,Lukas G,Lagina A,Masterson S,Morley PT,Morrison LJ,Nehme Z,Norii T,Raffay V,Ristagno G,Samantaray A,Semeraaro F,Singh B,Smith CM,Vaillancourt C,Berg KM,Olasvegen TM;on behalf of the Basic Life Support Task Force Collaborators. Basic life support: 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations. Circula-tion 2025;152(suppl 1):S34-S71.doi:10.1161/CIR.00000000000001364

Disclosures

Writing Group Disclosures

|Writing group member|Employment|Research grant|Other research support|Speakers bureau/noronia witness|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Janet E. Bray|Monash University and Curtin University (Australia)|Australian Resuscitation Councilt; Laerdal Foundation; Heart Foundation of Australiatr|None|None|None|None|Australian Resuscitation Councilt|Elseviert; Heart Foundation of Australiat| |Michael A. Smythy A. Warwick (United Kingdom)|University of Warwick in Kingdom)|None|None|None|None|None|None|None| |Katherine M. Berg|Beth Israel Deaconess Medical Center and Harvard Medical School|None|None|None|None|None|AHA/ILCORt|None| |Rebecca E. Cash|Massachusetts General Hospital|NIHt; Society for Academic Emergency Medicine Foundationt|None|None|None|None|American College of Emergency Physicianst; Prehospital Guidelines Consortium*; Air Methods Corporationt|Massachusetts General Hospitalt| |Sung Phil Chung|Gangnam Severance Hospital, Yonsei University (South Korea)|None|None|None|None|None|None|None| |Julie Considine|Deakin University and Eastern Health(Australia)|None|None|None|None|None|None|None| |Katie N. Dainty|North York General Hospital (Canada)|AMS Healthcare*; Canadian Institutes of Health Research*|None|None|None|None|Healthcare*|Philips Healthcare| |Vihara Dassanayake|University of Colombo(Sri Lanka)|None|None|None|None|None|None|None| |Guillaume Debaty|University Hospital of Grenoble (France)|DGOS(national research grant)*; Advanced CPR solution*; Stryker*|None|None|None|None|None|None| |Maya Dewan|Cincinnati Children's Hospital Center|None|None|None|None|None|None|None| |Bridget Dicker|Hato Hone St John; Auckland University of Technology(New Zealand)|Health Research Council New Zealandt|None|None|None|None|None|Auckland University of Technolgy (AUT)t; Hato Hone St John New Zealand*|

$\text{(Continued)}$

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$$\text{ Basic Life Support: CoSTR 2025}$$

Writing Group Disclosures Continued

|Writing group member|Employment|Research grant|Other research support|Speakers bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Natasha Dodge|Monash University (Australia)|None|None|None|None|None|None|None| |Fredrik Folke|Gentofte University Hospital, Hellerup (Denmark)|None|None|None|None|None|None|None| |Carolina Malta Hansen|Copenhagen Emergency Medical Sevices (Denmark)|Laerdal Foundationt; Novo Nordisk Foundationt; Independent Research Fund Denmark; Helsefondent; Capital Region of Denmark Research Fund Fundt; TrygFondent Zollt|None|None|None|None|Duke Clinical Research Institutet|ERC 2025 Guidelines writing group*| |Takanari Ikeyama|Aichi Children's Health and Medical Center (Japan)|Japan Society for the Promotion of Science (JSPS)*|None|None|None|None|None|None| |Nicholas J. Johnson|University of Washington|NIHt; American Heart Associationt; Centers for Disease Control and Preventiont|None|None|None|None|None|None| |Anthony Lagina|Wayne State University|NIH*|None|None|2025 expert witness for defense, Aortic Dissection Case*|None|None|None| |George Lukas|Monash Health (Australia)|None|None|None|None|None|None|None| |Siobhan Masterson|HSE National Ambulance Service (Ireland)|None|None|None|None|None|None|None| |Peter T. Morley|University of Melbourne and Royal Melbourne Hospital (Australia)|None|None|None|None|None|None|None| |Laurie J. Morrison|St. Michael's Hospital and University of Toronto(Canada)|None|None|None|None|None|None|None| |Ziad Nehme|Ambulance Victoria and Monash University (Australia)|National Heart Foundationt; National Health and Medical Research Council|None|None|None|None|None|Rapid Response Revivalt| |Tatsuya Norii|The University of New Mexico|Japanese Association for Acute Medicine*|None|None|None|None|None|None| |Theresa M. Olasveengen|Oslo University Hospital and University of Oslo (Norway)|None|None|None|None|None|Laerdal Foundation*|None| |Gavin D. Perkins|Warwick Medical School and University Hospitals NHS Foundation Trust (United Kingdom)|BHFt; RCUkT; NIHRt|None|None|None|None|Elseviert|University Hospitals Coventry and Warwickshiret|

$$\text{(Continued)}$$

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$$\text{Basic Life Support:}\text{CoSTR 2025}$$

Writing Group Disclosures Continued

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

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

*Modest.

tSignificant.

Reviewer Disclosures

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

$\text{(Continued)}$

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Reviewer Disclosures Continued

|Reviewer|Employment|Research grant|Other research support|Speakers bureau/ honoraria|Expert honor|Ownership interest|Consultad/advisory board|Other| |---|---|---|---|---|---|---|---|---| |Jhma Sankar|All India Institute of Medical Sciences(India)|None|None|None|None|None|None|None|

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

*Modest.

tSignificant.

REFERENCES

1. International Liaison Committee on Resuscitation. ILCOR website. Ac-cessed January 10,2025.https://www.icorglu/

2.Morley PT, Berg KM, Billi JE, Nolan JP, Montgomery WH, Atkins DL, Bray JE,Carlson JN, de Caen AR, Djvar T, et al. Methodology and conflict of interest management: 2025 International Liaison Committee on Resusca-tion Consensus on Science With Treatment Recommendations. Circulation.2025;152(suppl 1):S23-S33. doi: 10.1161/CIR.00000000000001366

3.Greir R,Cheng A,Abelarias-Gómez C, Allan KS, Breckwald J, Cortegian A, Donoghue AJ,Eastwood KJ, Farquharson B, Hseih M-J,et al. Education,implementation, and teams: 2055 International Liaison Committee on Resus-citation Consensus on Science With Treatment Recommendations. Circulation,2025;152(suppl 1):S205-S249.doi:10.1161/CIR.00000000000001359

4.Drennan IR, Berg KM, Bottiger BW, Chia YW, Couper K, Crowley C, D'Arigo S, Deakin CD, Fernando SM, Garg R, et al. Advanced life support; 2025 International Liaison Committee on Resuscitation on Science 2025;155(spr1):10611/CIR.0000000000000013605515. doi: 10.1161/CIR.000000000000001360

5.Chung SP,Nehre Z,Johnson NL,Leagina A,Barry J,On behalf of the In-ternational Liaison Committee on Resuscitation LLCOR Basic LEC Support Task Force. Effects of personal protective equipment on cardiopulmonary resuscitation quality and outcomes: a systematic review. Resuscitation 2023;14:100398.10:1016/j.18rescu.2003.100398

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