Circulation
Part 3: Adult Basic and Advanced Life
Support
2020 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
TOP 10 TAKE-HOME MESSAGES FOR ADULT Ashish R. Panchal, MD,
CARDIOVASCULAR LIFE SUPPORT PhD, Chair
1. On recognition of a cardiac arrest event, a layperson should simultaneously Jason A. Bartos, MD, PhD
and promptly activate the emergency response system and initiate cardiopul- José G. Cabañas, MD,
monary resuscitation (CPR). MPH
2. Performance of high-quality CPR includes adequate compression depth and Michael W. Donnino, MD
rate while minimizing pauses in compressions, Ian R. Drennan, ACP,
3. Early defibrillation with concurrent high-quality CPR is critical to survival PhD(C)
Karen G. Hirsch, MD
when sudden cardiac arrest is caused by ventricular fibrillation or pulseless
Peter J. Kudenchuk, MD
ventricular tachycardia.
Michael C. Kurz, MD, MS
4. Administration of epinephrine with concurrent high-quality CPR improves
Eric J. Lavonas, MD, MS
survival, particularly in patients with nonshockable rhythms.
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Peter T. Morley, MBBS
5. Recognition that all cardiac arrest events are not identical is critical for opti-
Brian J. O’Neil, MD
mal patient outcome, and specialized management is necessary for many
Mary Ann Peberdy, MD
conditions (eg, electrolyte abnormalities, pregnancy, after cardiac surgery).
Jon C. Rittenberger, MD,
6. The opioid epidemic has resulted in an increase in opioid-associated out-of-
MS
hospital cardiac arrest, with the mainstay of care remaining the activation of
Amber J. Rodriguez, PhD
the emergency response systems and performance of high-quality CPR.
Kelly N. Sawyer, MD, MS
7. Post–cardiac arrest care is a critical component of the Chain of Survival and
Katherine M. Berg, MD,
demands a comprehensive, structured, multidisciplinary system that requires
Vice Chair
consistent implementation for optimal patient outcomes.
On behalf of the Adult
8. Prompt initiation of targeted temperature management is necessary for all
Basic and Advanced Life
patients who do not follow commands after return of spontaneous circula- Support Writing Group
tion to ensure optimal functional and neurological outcome.
9. Accurate neurological prognostication in brain-injured cardiac arrest survivors
is critically important to ensure that patients with significant potential for
recovery are not destined for certain poor outcomes due to care withdrawal.
10. Recovery expectations and survivorship plans that address treatment, surveil-
lance, and rehabilitation need to be provided to cardiac arrest survivors and
their caregivers at hospital discharge to optimize transitions of care to home
and to the outpatient setting.
PREAMBLE Key Words: AHA Scientific Statements
◼ apnea ◼ cardiopulmonary
In 2015, approximately 350 000 adults in the United States experienced non- resuscitation ◼ defibrillators ◼ delivery
of health care ◼ electric countershock
traumatic out-of-hospital cardiac arrest (OHCA) attended by emergency medical ◼ heart arrest ◼ life support care
services (EMS) personnel.1 Approximately 10.4% of patients with OHCA survive
© 2020 American Heart Association, Inc.
their initial hospitalization, and 8.2% survive with good functional status. The key
drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary https://www.ahajournals.org/journal/circ
S366 October 20, 2020 Circulation. 2020;142(suppl 2):S366–S468. DOI: 10.1161/CIR.0000000000000916
, Panchal et al Adult Basic and Advanced Life Support: 2020 AHA Guidelines for CPR and ECC
resuscitation (CPR) and public use of an automated equipment. Other recommendations are relevant to
external defibrillator (AED). Despite recent gains, only persons with more advanced resuscitation training,
39.2% of adults receive layperson-initiated CPR, and functioning either with or without access to resuscita-
the general public applied an AED in only 11.9% of tion drugs and devices, working either within or outside
cases.1 Survival rates from OHCA vary dramatically be- of a hospital. Some treatment recommendations in-
tween US regions and EMS agencies.2,3 After significant volve medical care and decision-making after return of
improvements, survival from OHCA has plateaued since spontaneous circulation (ROSC) or when resuscitation
2012. has been unsuccessful. Importantly, recommendations
Approximately 1.2% of adults admitted to US hos- are provided related to team debriefing and systematic
pitals suffer in-hospital cardiac arrest (IHCA).1 Of these feedback to increase future resuscitation success.
patients, 25.8% were discharged from the hospital
alive, and 82% of survivors have good functional sta-
tus at the time of discharge. Despite steady improve-
Organization of the Writing Group
ment in the rate of survival from IHCA, much oppor- The Adult Cardiovascular Life Support Writing Group
tunity remains. included a diverse group of experts with backgrounds
The International Liaison Committee on Resusci- in emergency medicine, critical care, cardiology, toxicol-
tation (ILCOR) Formula for Survival emphasizes 3 es- ogy, neurology, EMS, education, research, and public
sential components for good resuscitation outcomes: health, along with content experts, AHA staff, and the
guidelines based on sound resuscitation science, ef- AHA senior science editors. Each recommendation was
fective education of the lay public and resuscitation developed and formally approved by the writing group.
providers, and implementation of a well-functioning The AHA has rigorous conflict of interest policies
Chain of Survival.4 and procedures to minimize the risk of bias or improp-
These guidelines contain recommendations for ba- er influence during the development of guidelines. Be-
sic life support (BLS) and advanced life support (ALS) fore appointment, writing group members disclosed
for adult patients and are based on the best available all commercial relationships and other potential (in-
resuscitation science. The Chain of Survival, introduced cluding intellectual) conflicts. These procedures are
in Major Concepts, is now expanded to emphasize the described more fully in “Part 2: Evidence Evaluation
important component of survivorship during recovery and Guidelines Development.” Disclosure information
for writing group members is listed in Appendix 1.
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from cardiac arrest, requires coordinated efforts from
medical professionals in a variety of disciplines and, in
the case of OHCA, from lay rescuers, emergency dis- Methodology and Evidence Review
patchers, and first responders. In addition, specific rec-
ommendations about the training of resuscitation pro- These guidelines are based on the extensive evidence
viders are provided in “Part 6: Resuscitation Education evaluation performed in conjunction with the ILCOR and
Science,” and recommendations about systems of care affiliated ILCOR member councils. Three different types
are provided in “Part 7: Systems of Care.” of evidence reviews (systematic reviews, scoping reviews,
and evidence updates) were used in the 2020 process.
Each of these resulted in a description of the literature
INTRODUCTION that facilitated guideline development. A more compre-
hensive description of these methods is provided in “Part
Scope of the Guidelines 2: Evidence Evaluation and Guidelines Development.”
These guidelines are designed primarily for North Amer-
ican healthcare providers who are looking for an up-to-
date summary for BLS and ALS for adults as well as for
Class of Recommendation and Level of
those who are seeking more in-depth information on Evidence
resuscitation science and gaps in current knowledge. As with all AHA guidelines, each 2020 recommendation This table defines the Classes of Recommendation (COR) and Levels of Evidence (LOE). COR
indicates the strength the writing group assigns the recommendation, and the LOE is assigned
based on the quality of the scientific evidence. The outcome or result of the intervention
should be specified (an improved clinical outcome or increased diagnostic accuracy or
incremental prognostic information).
Classes of Recommendation
COR designations include Class 1, a strong recommendation for which the potential benefit
greatly outweighs the risk; Class 2a, a moderate recommendation for which benefit most likely
outweighs the risk; Class 2b, a weak recommendation for which it’s unknown whether benefit
The BLS care of adolescents follows adult guidelines. is assigned a Class of Recommendation (COR) based on
will outweigh the risk; Class 3: No Benefit, a moderate recommendation signifying that there is
equal likelihood of benefit and risk; and Class 3: Harm, a strong recommendation for which the
risk outweighs the potential benefit.
Suggested phrases for writing Class 1 recommendations include
• Is
recommended
• Is indicated/
useful/effective/beneficial
• Should be
performed/administered/other
Comparative-effectiveness phrases include treatment/strategy A is recommended/indicated in
preference to treatment B, and treatment A should be chosen over treatment B.
This Part of the 2020 American Heart Association (AHA) the strength and consistency of the evidence, alterna-
Suggested phrases for writing Class 2a recommendations include
• Is reasonable
• Can be useful/
effective/beneficial
Comparative-effectiveness phrases include treatment/strategy A is probably recommended/
indicated in preference to treatment B, and it is reasonable to choose treatment A over treatment B.
For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only),
studies that support the use of comparator verbs should involve direct comparisons of the
treatments or strategies being evaluated.
Suggested phrases for writing Class 2b recommendations include
• May/might be
reasonable
Guidelines for CPR and Emergency Cardiovascular Care tive treatment options, and the impact on patients and
• May/might be
considered
• Usefulness/
effectiveness is unknown/unclear/uncertain or not well-established
Suggested phrases for writing Class 3: No Benefit recommendations (generally,
LOE A or B use only) include
• Is not
recommended
• Is not
indicated/useful/effective/beneficial
• Should not be
performed/administered/other
includes recommendations for clinical care of adults society (Table 1). The Level of Evidence (LOE) is based on
Suggested phrases for writing Class 3: Harm recommendations include
• Potentially
harmful
• Causes harm
• Associated
with excess morbidity/mortality
• Should not be
performed/administered/other
Levels of Evidence
For LOEs, the method of assessing quality is evolving, including the application of standardized,
widely-used, and preferably validated evidence grading tools; and for systematic reviews, the
incorporation of an Evidence Review Committee. LOE designations include Level A, Level B-R,
with cardiac arrest, including those with life-threaten- the quality, quantity, relevance, and consistency of the
Level B-NR, Level C-LD, and Level C-EO.
Those categorized as Level A are derived from
• High-quality
evidence from more than 1 randomized clinical trial, or RCT
• Meta-analyses
of high-quality RCTs
• One or more
RCTs corroborated by high-quality registry studies
Those categorized as Level B-R (randomized) are derived from
• Moderate-
quality evidence from 1 or more RCTs
• Meta-analyses
ing conditions in whom cardiac arrest is imminent, and available evidence. For each recommendation, the writ-
of moderate-quality RCTs
Those categorized as Level B-NR (nonrandomized) are derived from
•
Moderate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies,
observational studies, or registry studies
• Meta-analyses
of such studies
Those categorized as Level C-LD (limited data) are derived from
• Randomized or
nonrandomized observational or registry studies with limitations of design or execution
• Meta-analyses
of such studies
after successful resuscitation from cardiac arrest. ing group discussed and approved specific recommen-
• Physiological
or mechanistic studies in human subjects
Those categorized as Level C-EO (expert opinion) are derived from
• Consensus of
expert opinion based on clinical experience
COR and LOE are determined independently (any COR may be paired with any LOE).
A recommendation with LOE C does not imply that the recommendation is weak. Many
important clinical questions addressed in guidelines do not lend themselves to clinical trials.
Although RCTs are unavailable, there may be a very clear clinical consensus that a particular
test or therapy is useful or effective.
Some recommendations are directly relevant to lay dation wording and the COR and LOE assignments. In
rescuers who may or may not have received CPR train- determining the COR, the writing group considered
ing and who have little or no access to resuscitation the LOE and other factors, including systems issues,
Circulation. 2020;142(suppl 2):S366–S468. DOI: 10.1161/CIR.0000000000000916 October 20, 2020 S367
, Panchal et al Adult Basic and Advanced Life Support: 2020 AHA Guidelines for CPR and ECC
Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient
Care (Updated May 2019)*
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economic factors, and ethical factors such as equity, ac- or 1 or more RCT corroborated by high-quality registry
ceptability, and feasibility. These evidence-review meth- studies.) Thirty-seven recommendations are supported
ods, including specific criteria used to determine COR by Level B-Randomized Evidence (moderate evidence
and LOE, are described more fully in “Part 2: Evidence from 1 or more RCTs) and 57 by Level B-Nonrandom-
Evaluation and Guidelines Development.” The Adult ized evidence. The majority of recommendations are
Basic and Advanced Life Support Writing Group mem- based on Level C evidence, including those based on
bers had final authority over and formally approved limited data (123 recommendations) and expert opin-
these recommendations. ion (31 recommendations). Accordingly, the strength
Unfortunately, despite improvements in the design of recommendations is weaker than optimal: 78 Class
and funding support for resuscitation research, the 1 (strong) recommendations, 57 Class 2a (moderate)
overall certainty of the evidence base for resuscita- recommendations, and 89 Class 2b (weak) recommen-
tion science is low. Of the 250 recommendations in dations are included in these guidelines. In addition, 15
these guidelines, only 2 recommendations are sup- recommendations are designated Class 3: No Benefit,
ported by Level A evidence (high-quality evidence and 11 recommendations are Class 3: Harm. Clinical
from more than 1 randomized controlled trial [RCT], trials in resuscitation are sorely needed.
S368 October 20, 2020 Circulation. 2020;142(suppl 2):S366–S468. DOI: 10.1161/CIR.0000000000000916
, Panchal et al Adult Basic and Advanced Life Support: 2020 AHA Guidelines for CPR and ECC
Guideline Structure Our Constituencies: A Report of the American College of Cardiology/
American Heart Association Task Force on Clinical Practice Guidelines. Cir-
The 2020 Guidelines are organized into knowledge culation. 2019;139:e879–e886. doi: 10.1161/CIR.0000000000000651
chunks, grouped into discrete modules of information
on specific topics or management issues.5 Each modular Abbreviations
knowledge chunk includes a table of recommendations ACD active compression-decompression
that uses standard AHA nomenclature of COR and LOE. ACLS advanced cardiovascular life support
A brief introduction or short synopsis is provided to ADC apparent diffusion coefficient
put the recommendations into context with important
AED automated external defibrillator
background information and overarching management
AHA American Heart Association
or treatment concepts. Recommendation-specific text
clarifies the rationale and key study data supporting the ALS advanced life support
recommendations. When appropriate, flow diagrams aOR adjusted odds ratio
or additional tables are included. Hyperlinked refer- AV atrioventricular
ences are provided to facilitate quick access and review. BLS basic life support
COR Class of Recommendation
Document Review and Approval CoSTR International Consensus on Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care Science With
Each of the 2020 Guidelines documents was submitted Treatment Recommendations
for blinded peer review to 5 subject-matter experts
CPR cardiopulmonary resuscitation
nominated by the AHA. Before appointment, all peer
CT computed tomography
reviewers were required to disclose relationships with
industry and any other conflicts of interest, and all dis- DWI diffusion-weighted imaging
closures were reviewed by AHA staff. Peer reviewer ECG electrocardiogram
feedback was provided for guidelines in draft format ECPR extracorporeal cardiopulmonary resuscitation
and again in final format. All guidelines were reviewed EEG electroencephalogram
and approved for publication by the AHA Science Advi-
EMS emergency medical services
sory and Coordinating Committee and the AHA Execu-
ETCO2 (partial pressure of) end-tidal carbon dioxide
tive Committee. Disclosure information for peer review-
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ers is listed in Appendix 2. ETI endotracheal intubation
GWR gray-white ratio
ICU intensive care unit
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