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General Cardiac Arrest Care

Date Last Search Run: Jun 11, 2024
Table last updated: Jun 08, 2024
Data last added: May 27, 2024

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)
2 (fair evidence exists)
3 (weak evidence exists)  


Interventions

ACDC
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Neuro intact survival Patient Aufderheide TP., Frascone RJ., Wayne MA., Mahoney BD., Swor RA., Domeier RM., et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: A randomised trial. Lancet 2011; 377(9762):301-11. Medline
I Supportive (Green) ETCO2 measurement of CPR efficacy Process PH-Paramedic Orliaguet GA., Carli PA., Rozenberg A., Janniere D., Sauval P., Delpech P. End-tidal carbon dioxide during out-of-hospital cardiac arrest resuscitation: Comparison of active compression-decompression and standard CPR. Ann Emerg Med 1995; 25(1):48-51. Medline
I Supportive (Green) ROSC, 1 hour , 1 month, DC and DC neuro outcome Patient ED-MD Plaisance P., Adnet F., Vicaut E., et al. Benefit of active compression-decompression cardiopulmonary resuscitation as a prehospital advanced cardiac life support. A randomized multicenter study. Circulation 1997; 95(4):955-61. Medline
I Supportive (Green) Survival Patient PH-Paramedic Skogvoll E., Wik L. Active compression-decompression cardiopulmonary resuscitation: A population-based, prospective randomised clinical trial in out-of-hospital cardiac arrest. Resuscitation 1999; 42(3):163-172. Medline
I Supportive (Green) Survival for one hour and to discharge Patient ED-MD Stiell IG., Hebert PC., Wells GA., et al. The ontario trial of active compression-decompression cardiopulmonary resuscitation for in-hospital and prehospital cardiac arrest. JAMA 1996; 275(18):1417-1423. Medline
I Neutral (Yellow) In-hospital mortality Patient ED-MD Frascone RJ., Wayne MA., Swor RA., et al. Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device. Resuscitation 2013; 84(9):1214-22. Medline
I Neutral (Yellow) Mortality Patient PH-Paramedic Lafuente-Lafuente C., Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software Medline
I Neutral (Yellow) Supportive (Green) Patient ED-MD Plaisance P., et al. A comparison of standard CPR and ACDC for OOHCA. NEJM 1999; 341:569-75. Medline
I Neutral (Yellow) ROSC Patient PH-Paramedic Schwab TM., Callaham ML., Madsen CD., Utecht TA. A randomized clinical trial of active compression-decompression CPR vs standard CPR in out-of-hospital cardiac arrest in two cities. JAMA 1995; 273(16):1261-1268. Medline
I Neutral (Yellow) ROSC Patient PH-Paramedic Wang CH., Tsai MS., Chang WT., et al. Active compression-decompression resuscitation and impedance threshold device for out-of-hospital cardiac arrest: A systematic review and metaanalysis of randomized controlled trials. Crit Care Med 2015; 43(4):889-896. Medline
II Supportive (Green) survival to hospital discharge Patient PH-Paramedic Ong ME., et al. Use of an automated, load-distributing band chest compression device for out-of-hospital cardiac arrest resuscitation. JAMA 2006; 295(22):2629-37. Medline
II Supportive (Green) Survival (alive upon ED admission) Patient PH-Paramedic Thayne RC., Thomas DC., Neville JD., Van Dellen A. Use of an impedance threshold device improves short-term outcomes following out-of-hospital cardiac arrest. Resuscitation 2005; 67(1):103-8. Medline
II Neutral (Yellow) ROSC Patient Gunyadin YK., Cekmen B., Alkilli NB., Koylu R., Sert ET., Cander B. Comparative effectiveness of standard CPR vs active compression-decompression CPR with CardioPump for treatment of cardiac arrest. Am J Emerg Med 2016; 34(3):542-7. Medline
III Supportive (Green) PETCO2 levels Patient PH-Paramedic Axelsson C., Karlsson T., Axelsson AB., Herlitz J. Mechanical active compression-decompression cardiopulmonary resuscitation (ACD-CPR) versus manual CPR according to pressure of end tidal carbon dioxide (P(ET)CO2) during CPR in out-of-hospital cardiac arrest (OHCA). Resuscitation 2009; 80(10):1099-103. Medline
III Supportive (Green) Neurologic Recovery Patient PH-Paramedic Holmstrom P., Boyd J., Sorsa M., Kuisma M. A case of hypothermic cardiac arrest treated with an external chest compression device (LUCAS) during transport to re-warming. Resuscitation 2005; 67(1):139-41. Medline
III Supportive (Green) ROSC Patient PH-Paramedic Lurie KG., Shultz JJ., Callaham ML., et al. Evaluation of active compression-decompression CPR in victims of out-of-hospital cardiac arrest. JAMA 1994; 271(18):1405-11. Medline

ACLS
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival at hospital discharge Patient PH-Paramedic Bakalos G. Advanced Life Support versus Basic Life Support in the Pre-Hospital Setting: A Meta-Analysis. Resuscitation 2011; 82:1130-7. Medline
I Supportive (Green) Survival to discharge Process PH-Paramedic Wang SA, Lee HW, Ko YC, et al. Effect of crew ratio of advanced life support-trained personnel on patients with out-of-hospital cardiac arrest: A systematic review and meta-analysis. J Formos Med Assoc October 2023. Medline
I Supportive (Green) Survival to discharge Process ED-MD Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): A phase 2, single centre, open-label, randomised controlled trial. Lancet 2020; 396(10265):1807-16. Medline
II Supportive (Green) Survival to hospital discharge Patient Evans CC., Petersen A., Meier EN., Buick JE., Schreiber M., Kannas D, et al. Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries. The journal of trauma and acute care surgery 2016; 81(2):285-93. Medline
II Supportive (Green) 1-month survival Patient PH-Paramedic Hagihara A, Onozuka D, Nagata T, Hasegawa M. Effects of advanced life support on patients who suffered cardiac arrest outside of hospital and were defibrillated. Am J Emerg Med 2018; 36(1):73-8 Medline
II Supportive (Green) ROSC Patient PH-Paramedic Ma M., et al. Outcomes from OOHCA in Metro Taipan: does and ALS service make a difference? Resuscitation 2007; 74:461-9. Medline
II Supportive (Green) Survival to discharge Patient PH-Paramedic Markel DT., Gold LS., Fahrenbruch CE., Eisenberg MS. Prompt ALS Improves Survival VF. Prehospital Emerg Care 2009; 13(3):329-34. Medline
II Supportive (Green) Survival to discharge Patient Morgenstern J., Heitz C., Milne WK. Hot Off the Press: Prehospital Advanced Cardiac Life Support for Out-of-hospital Cardiac Arrest. Academic Emergency Medicine 2018; 25(4):453-455. Medline
II Supportive (Green) Survival to hospital discharge Patient PH-Paramedic Nichol G., Detsky AS., Stiell IG., O'Rourke K., Wells G., Laupacis A. Effectiveness of emergency medical services for victims of out-of-hospital cardiac arrest: A metaanalysis. Ann Emerg Med 1996; 27(6):700-10. Medline
II Supportive (Green) Quality of life Patient PH-Paramedic van Alem AP., Waalewijn RA., Koster RW., de Vos R. Assessment of quality of life and cognitive function after out-of-hospital cardiac arrest with successful resuscitation. Am J Cardiol 2004; 93(2):131-135. Medline
II Supportive (Green) Survival to hospital discharge Patient PH-Paramedic Woodall J., McCarthy M., Johnston T., Tippett V., Bonham R. Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service. EMJ 2007; 24:134-8. Medline
II Supportive (Green) Neurological outcome at hospital discharge Patient PH-Paramedic Yang HC, Park SM, Lee KJ, et al. Delayed arrival of advanced life support adversely affects the neurological outcome in a multi-tier emergency response system. Am J Emerg Med 2023; 71:1-6. Medline
II Neutral (Yellow) Resuscitation rates and 1-month survival rates Patient PH-Paramedic Ohshige K., et al. Evaluation of OOHCA resuscitation with resuscitative drugs: a prospective comparative study in Japan. Resus 2005; 66:53-61. Medline
II Neutral (Yellow) Survival Patient PH-Paramedic Ryynanen OP., Iirola T., Reitala J., Palve H., Malmivaara A. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med 2010; 18:62-7241-18-62. Medline
II Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Sanghavi P., Jena AB., Newhouse JP., Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med 2015; 175(2):196-204. Medline
II Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Sanghavi P., Jena AB., Newhouse JP., Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med 2015; 175(2):196-204. Medline
II Neutral (Yellow) Peak expiratory flow rate Patient PH-Paramedic Stiell IG., et al. Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest. NEJM 2004; 351:647-56. Medline
II Opposes (Red) Survival and Neurological Recovery at 1 month Patient Hagihara A., Onozuka D., Nagata T., Hasegawa M. Effects of advanced life support on patients who suffered cardiac arrest outside of hospital and were defibrillated. Am J Emerg Med 2018; 36(1):73-8. Medline
II Opposes (Red) Survival and Neurological Recovery at 1 month Patient Hagihara A., Onozuka D., Nagata T., Hasegawa M. Effects of advanced life support on patients who suffered cardiac arrest outside of hospital and were defibrillated. Am J Emerg Med 2018; 36(1):73-8. Medline
II Opposes (Red) Sustained ROSC >20 min Patient PH-Paramedic Stupca K, Scaturo N, Shomo E, King T, Frank M. Esmolol, vector change, and dose-capped epinephrine for prehospital ventricular fibrillation or pulseless ventricular tachycardia. Am J Emerg Med 2023; 64:46-50. Medline
III Neutral (Yellow) ROSC Patient PH-Paramedic Rittenberger JC., et al. Predictors of ROSC in witnessed aeromedical cardiac arrests. Resuscitation 2008; 76:43-6. Medline
X Not Yet Graded (White) - Ahn JY, Ryoo HW, Jung H, Ro YS, Park JH. Impact of emergency medical service with advanced life support training for adults with out-of-hospital cardiac arrest in the Republic of Korea: A retrospective multicenter study. PLoS One 2023; 18(6):e0286047. Medline

Balanced crystalloids
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Arterial blood gas results Process ED-MD Woo JH, Lim YS, Cho JS, Yang HJ, Jang JH, Choi JY, Choi WS. Saline versus Plasma Solution-A in Initial Resuscitation of Patients with Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. J Clin Med July 2023; 12(15). Medline

BCLS
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival at hospital discharge Patient PH-Paramedic Bakalos G. Advanced Life Support versus Basic Life Support in the Pre-Hospital Setting: A Meta-Analysis. Resuscitation 2011; 82:1130-7. Medline
II Supportive (Green) Proportion of Pre-shock pause under 20 sec Process PH-Paramedic Cheskes S., Hillier M., Byers A., et al. The association between manual mode defibrillation, pre-shock pause duration and appropriate shock delivery when employed by basic life support paramedics during out-of-hospital cardiac arrest. Resuscitation 2015; 90:61-6. Medline
II Supportive (Green) Survival to discharge Patient PH-Paramedic Markel DT., Gold LS., Fahrenbruch CE., Eisenberg MS. Prompt ALS Improves Survival VF. Prehospital Emerg Care 2009; 13(3):329-34. Medline
II Supportive (Green) Survival Patient PH-Paramedic Ryynanen OP., Iirola T., Reitala J., Palve H., Malmivaara A. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med 2010; 18:62-7241-18-62. Medline
II Supportive (Green) Survival to hospital discharge Patient PH-Paramedic Sanghavi P., Jena AB., Newhouse JP., Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med 2015; 175(2):196-204. Medline
II Supportive (Green) Survival Patient PH-Paramedic Stiell IG., et al. Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest. NEJM 2004; 351:647-56. Medline
II Neutral (Yellow) ROSC Patient PH-Paramedic Ma M., et al. Outcomes from OOHCA in Metro Taipan: does and ALS service make a difference? Resuscitation 2007; 74:461-9. Medline
II Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Nichol G., Detsky AS., Stiell IG., O'Rourke K., Wells G., Laupacis A. Effectiveness of emergency medical services for victims of out-of-hospital cardiac arrest: A metaanalysis. Ann Emerg Med 1996; 27(6):700-10. Medline
II Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Woodall J., McCarthy M., Johnston T., Tippett V., Bonham R. Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service. EMJ 2007; 24:134-8. Medline

Blood Glucose Monitoring
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Utility Process PH-Paramedic Abramson TM, Bosson N, Loza-Gomez A, Eckstein M, Gausche-Hill M. Utility of Glucose Testing and Treatment of Hypoglycemia in Patients with Out-of-Hospital Cardiac Arrest. Prehosp Emerg Care 2022; 26(2):173–8. Medline

Bystander CCC
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival Patient PH-Bystander Bielski K, Smereka J, Chmielewski J, Pruc M, Chirico F, Gasecka A, et al. Meta-analysis of chest compression-only versus conventional cardiopulmonary resuscitation by bystanders for adult with out-of-hospital cardiac arrest. Cardiol J 2021. Medline
I Supportive (Green) Survival to hospital discharge Patient Zhan L., Yang LJ., Huang Y., He Q., Liu GJ. Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest. The Cochrane database of systematic reviews 2017; 3:CD010134. Medline
II Supportive (Green) Neurologically favorable survival Patient Fukuda T., Ohashi-Fukuda N., Kondo Y., Sera T., Yahagi N. Effect of rescue breathing by lay rescuers for out-of-hospital cardiac arrest caused by respiratory disease: a nationwide, population-based, propensity score-matched study. Internal and emergency medicine 2017; 12(4):493-501. Medline
II Supportive (Green) Survival Patient PH-Bystander Ivan I, Budiman F, Ruby R, Wendi IP, Ridjab DA. Current evidence of survival benefit between chest-compression only versus standard cardiopulmonary resuscitation in out-of-hospital cardiac arrest : Updated systematic review and meta-analysis of randomized controlled trials with trial sequential analysi. Herz 2021; 46(S2):198–208. Medline
II Supportive (Green) 1-month survival with favourable neurological outcome Patient PH-Bystander Iwami T., Kitamura T., Kiyohara K., Kawamura T. Dissemination of chest compression-only cardiopulmonary resuscitation and survival after out-of-hospital cardiac arrest. Circulation 2015; 132(5):415-22. Medline
II Supportive (Green) All-causes survival at 30 days Patient PH-Paramedic & MD Javaudin F, Raiffort J, Desce N, Baert V, Hubert H, Montassier E, et al. Neurological Outcome of Chest Compression-Only Bystander CPR in Asphyxial and Non-Asphyxial Out-Of-Hospital Cardiac Arrest: An Observational Study. Prehosp Emerg Care 2020:1-25. Medline
II Supportive (Green) Neurological function at 1 month Patient PH-Paramedic Kitamura T., Iwami T., Kawamura T., et al. Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: A prospective, nationwide, population-based cohort study. Lancet 2010; 375(9723):1347-54. Medline
II Supportive (Green) 1-month neurologically favourable survival Patient PH-Paramedic Maeda T., Kamikura T., Tanaka Y., et al. Impact of bystander-performed ventilation on functional outcomes after cardiac arrest and factors associated with ventilation-only cardiopulmonary resuscitation: A large observational study. Resuscitation 2015; 91:122-30. Medline
II Supportive (Green) Survival to discharge Patient PH-Paramedic Ong ME., Ng FS., Anushia P., et al. Comparison of chest compression only and standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest in singapore. Resuscitation 2008; 78(2):119-26. Medline
II Supportive (Green) Favourable neurological outcome Patient PH-Paramedic SOS-KANTO study group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): An observational study. Lancet 2007; 369(9565):920-926. Medline
II Neutral (Yellow) Neurological function at 1 month Patient PH-Paramedic Kitamura T., Iwami T., Kawamura T., et al. Time-dependent effectiveness of chest compression-only and conventional cardiopulmonary resuscitation for out-of-hospital cardiac arrest of cardiac origin. Resuscitation 2011; 82(1):3-9. Medline
III Neutral (Yellow) CPR quality Patient SIM Hong DY., Park SO., Lee KR., Baek KJ., Shin DH. A different rescuer changing strategy between 30:2 cardiopulmonary resuscitation and hands-only cardiopulmonary resuscitation that considers rescuer factors: A randomised cross-over simulation study with a time-dependent analysis. Resuscitation 2012; 83(3):353-9. Medline

Bystander CPR
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Rate of bystander-initiated CPR Process PH-Paramedic Ringh M., Rosenqvist M., Hollenberg J., et al. Mobile-phone dispatch of laypersons for CPR in out-of-hospital cardiac arrest. N Engl J Med 2015; 372(24):2316-25. Medline
II Supportive (Green) In-hospital or 30 day mortality Patient PH-Bystander Bielski K, Smereka J, Chmielewski J, Pruc M, Chirico F, Gasecka A, et al. Meta-analysis of chest compression-only versus conventional cardiopulmonary resuscitation by bystanders for adult with out-of-hospital cardiac arrest. Cardiol J 2021. Medline
II Supportive (Green) Bystander interventions; incidence and outcome of OHCA; 30-day survival. Process Other Gantzel Nielsen C, Andelius LC, Hansen CM, Blomberg SNF, Christensen HC, Kjølbye JS, et al. Bystander interventions and survival following out-of-hospital cardiac arrest at Copenhagen International Airport. Resuscitation 2021. Medline
II Supportive (Green) ROSC Patient PH-Bystander Grubic N, Hill B, Phelan D, Baggish A, Dorian P, Johri AM. Bystander interventions and survival after exercise-related sudden cardiac arrest: a systematic review. Br J Sport Med 2022; 56(7):410–6. Medline
II Supportive (Green) Survival to hospital discharge with good neurological outcome Patient PH-Bystander Grubic N, Peng YP, Walker M, Brooks SC; CARES Surveillance Group. Bystander-initiated cardiopulmonary resuscitation and automated external defibrillator use after out-of-hospital cardiac arrest: Uncovering disparities in care and survival across the urban-rural spectrum. Resuscitation 2022; 175:150–8. Medline
II Supportive (Green) Survival at hospital discharge with good neurological outcome Process Other Hong Tuan Ha V, Jost D, Bougouin W, Joly G, et al. Trends in survival from out-of-hospital cardiac arrest with a shockable rhythm and its association with bystander resuscitation: a retrospective study. Emerg Med J August 2023. Medline
II Supportive (Green) Survival Patient PH-Bystander Ivan I, Budiman F, Ruby R, Wendi IP, Ridjab DA. Current evidence of survival benefit between chest-compression only versus standard cardiopulmonary resuscitation in out-of-hospital cardiac arrest : Updated systematic review and meta-analysis of randomized controlled trials with trial sequential analysi. Herz 2021; 46(S2):198–208. Medline
II Supportive (Green) Neurologic recovery at the discharge Patient PH-Bystander Kim MW, Kim TH, Song KJ, Shin SD, Kim CH, Lee EJ, et al. Comparison between dispatcher-assisted bystander CPR and self-led bystander CPR in out-of-hospital cardiac arrest (OHCA). Resuscitation 2021; 158:64-70. Medline
II Supportive (Green) Good neurological recovery at discharge Patient PH-Bystander Kim SH, Park JH, Jeong J, Ro YS, Hong KJ, Song KJ, Do Shin S. Bystander cardiopulmonary resuscitation, automated external defibrillator use, and survival after out-of-hospital cardiac arrest. Am J Emerg Med April 2023; 66:85-90. Medline
II Supportive (Green) Neurological function at 1 month Patient PH-Paramedic Kitamura T., Iwami T., Kawamura T., et al. Time-dependent effectiveness of chest compression-only and conventional cardiopulmonary resuscitation for out-of-hospital cardiac arrest of cardiac origin. Resuscitation 2011; 82(1):3-9. Medline
II Supportive (Green) 1-year risks of anoxic brain damage Patient Kragholm K., Wissenberg M., Mortensen RN., Hansen SM., Malta HC., Thorsteinsson K., et al. Bystander Efforts and 1-Year Outcomes in Out-of-Hospital Cardiac Arrest. N Engl J Med 2017; 376(18):1737-47. Medline
II Supportive (Green) Survival Patient PH-Bystander Lee J, Lee W, Lee YJ, Sim H, Lee WK. Effectiveness of bystander cardiopulmonary resuscitation in improving the survival and neurological recovery of patients with out-of-hospital cardiac arrest: A nationwide patient cohort study. PLoS One 2020; 15(12):e0243757. Medline
II Supportive (Green) Survival Patient Lee M., Demirtas D., Buick JE., Feldman MJ., Cheskes S., Morrison LJ., et al. Increased cardiac arrest survival and bystander intervention in enclosed pedestrian walkway systems. Resuscitation 2017; 118:1-7. Medline
II Supportive (Green) 1-month neurologically favourable survival Patient PH-Paramedic Maeda T., Kamikura T., Tanaka Y., et al. Impact of bystander-performed ventilation on functional outcomes after cardiac arrest and factors associated with ventilation-only cardiopulmonary resuscitation: A large observational study. Resuscitation 2015; 91:122-30. Medline
II Supportive (Green) 1 month survival with favourable neurological function Patient PH-Paramedic Miyako J, Nakagawa K, Sagisaka R, et al. Association between bystander intervention and emergency medical services and the return of spontaneous circulation in out-of-hospital cardiac arrests occurring at a train station in the Tokyo metropolitan area: A retrospective cohort study. Resusc Plus August 2023; 15:100438. Medline
II Supportive (Green) Survival to Discharge Patient PH-Bystander Nguyen DD, Spertus JA, Kennedy KF, et al. Association Between Delays in Time to Bystander CPR and Survival for Witnessed Cardiac Arrest in the United States. Circ Cardiovasc Qual Outcomes 2023:e010116. Medline
II Supportive (Green) Survival to hospital discharge Patient PH-Paramedic Nichol G., Detsky AS., Stiell IG., O'Rourke K., Wells G., Laupacis A. Effectiveness of emergency medical services for victims of out-of-hospital cardiac arrest: A metaanalysis. Ann Emerg Med 1996; 27(6):700-10. Medline
II Supportive (Green) 30-day survival Patient Nord A., Svensson L., Karlsson T., Claesson A., Herlitz J., Nilsson L. Increased survival from out-of-hospital cardiac arrest when off duty medically educated personnel perform CPR compared with laymen. Resuscitation 2017; 120:88-94. Medline
II Supportive (Green) Discharge from hospital with favourable neuro Patient PH-Paramedic Olasveengen TM., Wik L., Steen PA. Standard basic life support vs. continuous chest compressions only in out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2008; 52(7):914-9. Medline
II Supportive (Green) Survival to discharge Patient PH-Paramedic Ong ME., Ng FS., Anushia P., et al. Comparison of chest compression only and standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest in singapore. Resuscitation 2008; 78(2):119-26. Medline
II Supportive (Green) Survival to hospital discharge Patient Park GJ., Song KJ., Shin SD., Lee KW., Ahn KO., Lee EJ., et al. Timely bystander CPR improves outcomes despite longer EMS times. Am J Emerg Med 2017; 35(8):1049-1055. Medline
II Supportive (Green) 30-day survival Patient Rajan S., Wissenberg M., Folke F., Hansen SM., Gerds TA., Kragholm K., et al. Association of Bystander Cardiopulmonary Resuscitation and Survival According to Ambulance Response Times After Out-of-Hospital Cardiac Arrest. Circulation 2016; 134(25):2095-104. Medline
II Supportive (Green) Hospital length of stay and ICU admission. Process Riddersholm S., Kragholm K., Mortensen RN., Pape M., Hansen CM., Lippert FK., et al. Association of bystander interventions and hospital length of stay and admission to intensive care unit in out-of-hospital cardiac arrest survivors. Resuscitation 2017; 119:99-106. Medline
II Supportive (Green) Favourable neurological outcome Patient PH-Paramedic SOS-KANTO study group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): An observational study. Lancet 2007; 369(9565):920-926. Medline
II Supportive (Green) Survival to hospital discharge. Patient PH-Paramedic Stiell IG., Wells GA., DeMaio VJ., et al. Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS study phase I results. Ontario prehospital advanced life support. Ann Emerg Med 1999; 33(1):44-50. Medline
II Supportive (Green) Shockable rhythm on first EKG Process Takahashi H., Sagisaka R., Natsume Y., Tanaka S., Takyu H., Tanaka H. Does dispatcher-assisted CPR generate the same outcomes as spontaneously delivered bystander CPR in Japan? Am J Emerg Med 2018; 36(3):384-91. Medline
II Supportive (Green) ROSC Patient Viereck S., Palsgaard Møller T., Kjær Ersbøll A., Folke F., Lippert F. Effect of bystander CPR initiation prior to the emergency call on ROSC and 30day survival-An evaluation of 548 emergency calls. Resuscitation 2017; 111:55-61. Medline
II Neutral (Yellow) Prolonged Shockable Rhythm time with bystander CPR Patient PH-Bystander Cournoyer A, Chauny JM, Paquet J, Potter B, Lamarche Y, de Montigny L, et al. Electrical rhythm degeneration in adults with out-of-hospital cardiac arrest according to the no-flow and bystander low-flow time. Resuscitation 2021. Medline
II Neutral (Yellow) 3-month survival with good neurological performance Patient PH-Bystander Sarkisian L, Abdi Isse Y, Gerke O, Emil Roelsgaard Obling L, et al. Survival and Neurological Outcome after Bystander versus Lay Responder Defibrillation in Out-of-Hospital Cardiac Arrest: A Sub-study of the BOX trial. Resuscitation Nov 2023; 110059. Medline
III Supportive (Green) CPR measures Process Gyllenborg T., Granfeldt A., Lippert F., Riddervold IS., Folke F. Quality of bystander cardiopulmonary resuscitation during real-life out-of-hospital cardiac arrest. Resuscitation 2017; 120:63-70. Medline
III Supportive (Green) CPR quality Patient SIM Hong DY., Park SO., Lee KR., Baek KJ., Shin DH. A different rescuer changing strategy between 30:2 cardiopulmonary resuscitation and hands-only cardiopulmonary resuscitation that considers rescuer factors: A randomised cross-over simulation study with a time-dependent analysis. Resuscitation 2012; 83(3):353-9. Medline
III Supportive (Green) Survival time Patient PH-Paramedic Wang HE., Min A., Hostler D., Chang CC., Callaway CW. Differential effects of out-of-hospital interventions on short- and long-term survival after cardiopulmonary arrest. Resuscitation 2005; 67(1):69-74. Medline
X Not Yet Graded (White) - Lafrance M, Recher M, Javaudin F, et al. Bystander basic life support and survival after out-of-hospital cardiac arrest: A propensity score matching analysis. Am J Emerg Med 2023; 67:135-43. Medline
X Not Yet Graded (White) - Simmons KM, McIsaac SM, Ohle R. Impact of community-based interventions on out-of-hospital cardiac arrest outcomes: a systematic review and meta-analysis. Sci Rep 2023; 13(1):10231. Medline

Calcium
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) No evidence of benefit for routine calcium administration for adult OHCA Patient Other Hsu CH, Couper K, Nix T, et al. Calcium during cardiac arrest: A systematic review. Resusc Plus 2023; 14:100379. Medline
II Opposes (Red) Survival to hospital admission Patient ED-MD Dillon DG, Wang RC, Shetty P, Douchee J, Rodriguez RM, Montoy JCC. Efficacy of emergency department calcium administration in cardiac arrest: A 9-year retrospective evaluation. Resuscitation August 2023; 191:109933. Medline
II Opposes (Red) 6 month and 1-year outcomes survival Patient PH-Paramedic Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Mærkedahl R, Mortensen LR, Nyboe R, Vandborg MP, Tarpgaard M, Runge C, Christiansen CF, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard H, Andersen LW.Effect of calcium vs. placebo on long-term outcomes in patients with out-of-hospital cardiac arrest. Resuscitation 2022; 179:21–4. Medline

Calcium (suspected hyper K)
Level Direction Primary Outcome Patient/Process Setting Reference
I Opposes (Red) ROSC or 30-day survival from PEA arrest Process PH-Paramedic Vallentin MF, Povlsen AL, Granfeldt A, Terkelsen CJ, Andersen LW. Effect of calcium in patients with pulseless electrical activity and electrocardiographic characteristics potentially associated with hyperkalemia and ischemia-sub-study of the Calcium for Out-of-hospital Cardiac Arrest (COCA) trial. Resuscitation Nov 2022; 181:150–7. Medline

Chest Compression devices
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) ROSC Patient Anantharaman V, Ng BL, Ang SH, Lee CY, Leong SH, Ong ME, et al. Prompt use of mechanical cardiopulmonary resuscitation in out-of-hospital cardiac arrest: The MECCA study report. Singapore Med J; 58(7):424-31. Medline
I Supportive (Green) Survival to admission Patient Bonnes JL., Brouwer MA., Navarese EP., Verhaert DV., Verheugt FW., Smeets JL., et al. Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med 2016; 67(3):349-60.e3. Medline
I Supportive (Green) ROSC Patient PH-Paramedic Chiang CY, Lim KC, Lai PC, Tsai TY, Huang YT, Tsai MJ. Comparison between Prehospital Mechanical Cardiopulmonary Resuscitation (CPR) Devices and Manual CPR for Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis. J Clin Med 2022; 11(5). Medline
I Supportive (Green) 30 day mortality Patient PH-Paramedic Perkins GD., Lall R., Quinn T., et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): A pragmatic, cluster randomised controlled trial. Lancet 2015; 385(9972):947-55. Medline
I Supportive (Green) Survival Patient PH-Paramedic Wang PL., Brooks SC. Mechanical versus manual chest compressions for cardiac arrest. The Cochrane database of systematic reviews 2018; 8 CD007260. Medline
I Neutral (Yellow) Long term outcomes (QoL) Patient Ji C., Lall R., Quinn T., Kaye C., Haywood K., Horton J., et al. Post-admission outcomes of participants in the PARAMEDIC trial: A cluster randomised trial of mechanical or manual chest compressions. Resuscitation 2017; 118:82-8. Medline
I Neutral (Yellow) Survival at 30 days Patient Khana S., Lonea A., Talluria S., et al. Efficacy and safety of mechanical versus manual compression in cardiac arrest – A Bayesian network meta-analysis. Resuscitation 2018; 130 182–188 Medline
I Neutral (Yellow) Serious or life-threatening visceral resuscitation-related damage Patient Koster RW., Beenen LF., van der BE., Spijkerboer AM., Tepaske R., van der WA., et al. Safety of mechanical chest compression devices AutoPulse and LUCAS in cardiac arrest: a randomized clinical trial for non-inferiority. Eur Heart J 2017; 38(40):3006-13. Medline
I Neutral (Yellow) In-hospital mortality Patient ED-MD Ong ME., Mackey KE., Zhang ZC., et al. Mechanical CPR devices compared to manual CPR during out-of-hospital cardiac arrest and ambulance transport: A systematic review. Scand J Trauma Resusc Emerg Med 2012; 20:39-7241-20-39. Medline
I Neutral (Yellow) Injuries Process PH-Paramedic Petrovich P, Berve PO, Barth-Heyerdahl Roald B, Wahl Kongsgård Hl. Injuries associated with mechanical chest compressions and active decompressions after out-of-hospital cardiac arrest: A subgroup analysis of non-survivors from a randomized study. Resusc Plus March 2023; 13:100362. Medline
I Neutral (Yellow) 4-hour survival Patient PH-Paramedic Rubertsson S., Lindgren E., Smekal D., et al. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: The LINC randomized trial. JAMA 2014; 311(1):53-61. Medline
I Neutral (Yellow) ROSC Patient PH-Paramedic Westfall M., Krantz S., Mullin C., Kaufman C., Mechanical Versus Manual Chest Compressions in Out-of-Hospital Cardiac Arrest: A Meta-Analysis. Crit Care 2013; 41: 7. Medline
I Opposes (Red) Survival to 4 hours after the 911 call Patient PH-Paramedic Hallstrom A., et al. Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA 2006; 295(22):2620-8. Medline
II Supportive (Green) ROSC Patient PH-Paramedic Chen YR, Liao CJ, Huang HC, Tsai CH, Su YS, Liu CH, et al. The Effect of Implementing Mechanical Cardiopulmonary Resuscitation Devices on Out-of-Hospital Cardiac Arrest Patients in an Urban City of Taiwan. Int J Environ Res Public Health 2021; 18(7). Medline
II Supportive (Green) Chest compression fraction Process PH-Paramedic Esibov A., Banville I., Chapman FW., Boomars R., Box M., Rubertsson S. Mechanical chest compressions improved aspects of CPR in the LINC trial. Resuscitation 2015; 91:116-21. Medline
II Supportive (Green) Efficacy of mechanical CPR Process PH-Paramedic Manoukian MAC, Tancredi DJ, Linvill MT, Wynia EH, Beaver B, Rose JS, Mumma BE. Manual versus Mechanical Delivery of High-Quality Cardiopulmonary Resuscitation on a River-Based Fire Rescue Boat. Prehosp Disaster Med 2022; 37(5):630–7. Medline
II Supportive (Green) CPC <2 at Discharge Patient ED-Paramedic & MD Mistraletti G, Lancioni A, Bassi G, et al. Mechanical chest compression and extracorporeal life support for out-of-hospital cardiac arrest. A 30-month observational study in the metropolitan area of Milan, Italy. Resuscitation Dec 2022; 182:109659. Medline
II Supportive (Green) ROSC Patient PH-Paramedic Omori K., Sato S., Sumi Y., et al. The analysis of efficacy for AutoPulse system in flying helicopter. Resuscitation 2013; 84(8):1045-50. Medline
II Supportive (Green) Feasibility Process Schmidbauer S., Herlitz J., Karlsson T., Axelsson C., Friberg H. Use of automated chest compression devices after out-of-hospital cardiac arrest in Sweden. Resuscitation 2017; 120:95-102. Medline
II Neutral (Yellow) ROSC on ED arrival Process PH-Paramedic Casner M., Anderson D., Isaacs M. The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest. Prehosp Emer Care 2005; 9(1):61-7. Medline
II Neutral (Yellow) ROSC Patient Other Frascone R, Pasquarella J, Hartigan M, Pasquarella C, Rupp P, Wewerka S. Automated Versus Manual Cardiopulmonary Resuscitation in Flight: Are We Being Safe? Air Med J 2022; 41(3):303–7. Medline
II Neutral (Yellow) ROSC Patient Hardig BM., Lindgren E., Östlund O., Herlitz J., Karlsten R., Rubertsson S. Outcome among VF/VT patients in the LINC (LUCAS IN cardiac arrest) trial-A randomised, controlled trial. Resuscitation 2017; 115:155-62. Medline
II Neutral (Yellow) Incidence and description of injury from mechanical CPR Patient PH-Paramedic Hayashi M, Tanizaki S, Nishida N, et al. Compression-associated injuries using CLOVER3000 device in non-survivor patients of OHCA: A retrospective cohort study. Am J Emerg Med March 2023; 68:127-31. Medline
II Neutral (Yellow) Units transfused Patient PH-Paramedic & MD Jennings PA., Harriss L., Bernard S., et al. An automated CPR device compared with standard chest compressions for out-of-hospital resuscitation. BMC Emerg Med 2012; 12:8-227X-12-8. Medline
II Neutral (Yellow) Hands off time. Process Maurin O., Frattini B., Jost D., Galinou N., Alhanati L., Dang MP., et al. Hands-off Time during Automated Chest Compression Device Application in Out-of-Hospital Cardiac Arrest: A Case Series Report. PEC 2016; 20(5):637-42. Medline
II Neutral (Yellow) Chest-compression associated injuries Patient ED-Paramedic & MD Ondruschka B., Baier C., Bayer R., Hammer N., DreBler J., Bernhard M. Chest compression-associated injuries in cardiac arrest patients treated with manual chest compressions versus automated chest compression devices (LUCAS II) - a forensic autopsy-based comparison. Forensic science, medicine, and pathology 2018; 14(4) 515-25. Medline
II Neutral (Yellow) Incidence of injury following mechanical CPR Process PH-Paramedic Preda T, Nafi M, Villa M, Cassina T. Traumatic injuries after manual and automatic mechanical compression during cardiopulmonary resuscitation, a retrospective cohort study. Resusc Plus Sept 2023; 16:100465. Medline
II Neutral (Yellow) Supportive of use of mechanical CPR in austere environment Process SIM Rupp SL, Overberger RC. Manual vs Mechanical Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest on a Ski Slope: A Pilot Study. Wilderness Env Med Sept 2023; 34(3):289-94. Medline
II Opposes (Red) Survival to hospital discharge Patient Hayashida K., Tagami T., Fukuda T., Suzuki M., Yonemoto N., Kondo Y., et al. Mechanical Cardiopulmonary Resuscitation and Hospital Survival Among Adult Patients With Nontraumatic Out-of-Hospital Cardiac Arrest Attending the Emergency Department: A Prospective, Multicenter, Observational Study in Japan (SOS-KANTO Survey of Survivo. Journal of the American Heart Association 2017; 6(11). Medline
II Opposes (Red) Good neurological outcome at discharge (CPC 1 or 2) Patient PH-Paramedic Jung E, Hong KJ, Shin SD, Ro YS, Ryu HH, Song KJ, et al. Interaction Effect Between Prehospital Mechanical Chest Compression Device Use and Post-Cardiac Arrest Care on Clinical Outcomes After Out-Of-Hospital Cardiac Arrest. J Emerg Med 2021. Medline
II Opposes (Red) Neurologic outcomes and survival to discharge Patient PH-Paramedic Min C, Lee DE, Ryoo HW, Jung H, Cho JW, et al. Neurologic outcomes of prehospital mechanical chest compression device use during transportation of out-of-hospital cardiac arrest patients: a multicenter observational study. Clin Exp Emerg Med 2022. Medline
II Opposes (Red) Survival to hospital discharge with favorable neurologic outcomes Patient Youngquist ST., Ockerse P., Hartsell S., Stratford C., Taillac P. Mechanical chest compression devices are associated with poor neurological survival in a statewide registry: A propensity score analysis. Resuscitation 2016; 106:102-7. Medline
III Supportive (Green) Feasibility Process SIM Alexander E, Katharina T, Verena F, Jürgen G, Maximilian N, Calvin K, et al. Comparison of different mechanical chest compression devices in the alpine rescue setting: a randomized triple crossover experiment. Scand J Trauma Resusc Emerg Med 2021; 29(1):84. Medline
III Supportive (Green) CPR quality Process SIM Fox J., Fiechter R., Gerstl P., et al. Mechanical versus manual chest compression CPR under ground ambulance transport conditions. Acute Card Care 2013; 15(1):1-6. Medline
III Supportive (Green) ROSC Patient Gao C., Chen Y., Peng H., Chen Y., Zhuang Y., Zhou S. Clinical evaluation of the AutoPulse automated chest compression device for out-of-hospital cardiac arrest in the northern district of Shanghai, China. AMS 2016; 12(3):563-70. Medline
III Supportive (Green) Time to first defibrillation Process Gyory RA., Buchle S.E, Rodgers D., Lubin JS. The Efficacy of LUCAS in Prehospital Cardiac Arrest Scenarios: A Crossover Mannequin Study. The western journal of emergency medicine 2017; 18(3):437-45. Medline
III Supportive (Green) Performance Process PH-Paramedic & MD Jörgens M, Königer J, Kanz KG, Birkholz T, Hübner H, Prückner S, et al. Testing mechanical chest compression devices of different design for their suitability for prehospital patient transport - a simulator-based study. BMC Emerg Med 2021; 21(1):18. Medline
III Supportive (Green) This observational manikin-based study aimed to evaluate the effect of the speed of ambulance on the quality of chest compression performed by the two different types of mechanical devices and manual chest compression. Process SIM Kamauzaman THT, Ngu JTH, Arithra A, Noh AYM, Siti-Azrin AH, Nor J. Simulation study on quality of CPR between manual chest compression and mechanical chest compression devices performed in ambulance. Med J Malaysia 2021; 76(2):171-6. Medline
III Supportive (Green) Survival to discharge Patient PH-Paramedic Risom M., Jorgensen H., Rasmussen LS., Sorensen AM. Resuscitation, prolonged cardiac arrest, and an automated chest compression device. J Emerg Med 2010; 38(4):481-3. Medline
III Supportive (Green) Injury Patient ED-MD Smekal D., Johansson J., Huzevka T., Rubertsson S. A pilot study of mechanical chest compressions with the LUCAS device in cardiopulmonary resuscitation. Resuscitation 2011; 82(6):702-706. Medline
III Supportive (Green) Effectiveness of chest compressions Process SIM Szarpak L, Truszewski Z, Czyzewski L, Frass M, Robak O. CPR using the lifeline ARM mechanical chest compression device: a randomized, crossover, manikin trial. Am J Emerg Med 2017; 35(1):96-100. Medline
III Neutral (Yellow) ROSC Patient PH-Paramedic Axelsson C., Nestin J., Svensson L., Axelsson AB., Herlitz J. Clinical consequences of the introduction of mechanical chest compression in the EMS system for treatment of OOHCA - a pilot study. Resuscitation 2006; 71:47-55. Medline
III Neutral (Yellow) CPR quality Process SIM Gassler H., Ventzke MM., Lampl L., Helm M. Transport with ongoing resuscitation: A comparison between manual and mechanical compression. Emerg Med J 2013; 30(7):589-92. Medline
III Neutral (Yellow) Quality of Chest Compressions Process SIM Kovic I., Lulic D., Lulic I. CPR PRO(R) device reduces rescuer fatigue during continuous chest compression cardiopulmonary resuscitation: A randomized crossover trial using a manikin model. J Emerg Med 2013; 45(4):570-7. Medline
III Neutral (Yellow) ROSC Patient PH-Paramedic Krep H., et al. OOHCA resuscitation with the autopulse system: a prospective observational study with a new load-distributing band chest compression device. Resus 2007; 73:86-95. Medline
III Neutral (Yellow) Correct compressions Process SIM Putzer G., Braun P., Zimmermann A., et al. LUCAS compared to manual cardiopulmonary resuscitation is more effective during helicopter rescue-a prospective, randomized, cross-over manikin study. Am J Emerg Med 2013; 31(2):384-9. Medline
III Neutral (Yellow) Hands off fraction Patient SIM Tomte O., Sunde K., Lorem T., et al. Advanced life support performance with manual and mechanical chest compressions in a randomized, multicentre manikin study. Resuscitation 2009; 80(10):1152-1157. Medline
III Opposes (Red) Time to Defibrillation and No Flow Time Process SIM Blomberg H., Gedeborg R., Berglund L., Karlsten R., Johansson J. Poor chest compression quality with mechanical compressions in simulated cardiopulmonary resuscitation: A randomized, cross-over manikin study. Resuscitation 2011; 82(10):1332-7. Medline
III Opposes (Red) Survival to hospital discharge with a favourable neurologic outcome Patient Newberry R., Redman T., Ross E., Ely R., Saidler C., Arana A., et al. No Benefit in Neurologic Outcomes of Survivors of Out-of-Hospital Cardiac Arrest with Mechanical Compression Device. Prehosp Emerg Care. 2018; 22(3):338-344. Medline
III Opposes (Red) Injury Patient PH-Paramedic Wind J., Bekkers SC., van Hooren LJ., van Heurn LW. Extensive injury after use of a mechanical cardiopulmonary resuscitation device. Am J Emerg Med 2009; 27(8):1017.e1-1017.e2. Medline
X Not Yet Graded (White) - Larik MO, Ahmed A, Shiraz MI, Shiraz SA, Anjum MU, Bhattarai P. Comparison of manual chest compression versus mechanical chest compression for out-of-hospital cardiac arrest: A systematic review and meta-analysis. Med February 2024; 103(8):e37294. Medline

Compressions directly after Defib
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Recurrence of VF Process PH-Paramedic Berdowski J., Tijssen JG., Koster RW. Chest compressions cause recurrence of ventricular fibrillation after the first successful conversion by defibrillation in out-of-hospital cardiac arrest. Circ Arrhythm Electrophysiol 2010; 3(1):72-8. Medline
III Supportive (Green) Time to Reoccurrence of VF/VT Process PH-Paramedic Blouin D., Topping C., Moore S., Stiell I., Afilalo M. Out-of-hospital defibrillation with automated external defibrillators: Postshock analysis should be delayed. Ann Emerg Med 2001; 38(3):256-61. Medline
III Supportive (Green) Risk of VF recurrence Patient PH-Paramedic Conover Z., Kern KB., Silver AE., Bobrow BJ., Spaite DW., Indik JH. Resumption of chest compressions after successful defibrillation and risk for recurrence of ventricular fibrillation in out-of-hospital cardiac arrest. Circ Arrhythm Electrophysiol 2014; 7(4):633-9. Medline

Continuous Oxymetry Monitoring
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) ROSC Patient PH-Paramedic Shin J, Walker R, Blackwood J, Chapman F, Crackel J, Kudenchuk P, et al. Cerebral oximetry during out-of-hospital resuscitation: Pilot Study of First Responder Implementation. Prehosp Emerg Care 2021; 1–7. Medline
II Supportive (Green) Prediction of ROSC Process ED-MD Tsukuda J., Fujitani S., Morisawa K., Shimozawa N., Lohman BD., Okamoto K., et al. Near-infrared spectroscopy monitoring during out-of-hospital cardiac arrest can the initial cerebral tissue oxygenation index predict ROSC? EMJ 2019; 36(1) 33-8. Medline
II Supportive (Green) Prediction of ROSC Process PH-Paramedic Xu J, Li C, Tang H, Tan D, Fu Y, Zong L, et al. Pulse oximetry waveform: A non-invasive physiological predictor for the return of spontaneous circulation in cardiac arrest patients ---- A multicenter, prospective observational study. Resuscitation 2021; 169:189–97. Medline
III Supportive (Green) Change in O2 level Process PH-Paramedic Frisch A., Suffoletto BP., Frank R., Martin-Gill C., Menegazzi JJ. Potential utility of near-infrared spectroscopy in out-of-hospital cardiac arrest: An illustrative case series. Prehosp Emerg Care 2012; 16(4):564-70. Medline
III Supportive (Green) Association between change in tissue oxygenation index and ROSC Patient PH-Paramedic Tsukuda J, Fujitani S, Rahman M, Morisawa K, Kawaguchi T, Taira Y. Monitoring tissue oxygenation index using near-infrared spectroscopy during pre-hospital resuscitation among out-of-hospital cardiac arrest patients: a pilot study. Scand J Trauma Resusc Emerg Med 2021; 29(1):42. Medline

CPR feedback device
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Survival to admission Patient Beesems SG, Berdowski J, Hulleman M, Blom MT, Tijssen JG, Koster RW. Minimizing pre- and post-shock pauses during the use of an automatic external defibrillator by two different voice prompt protocols. A randomized controlled trial of a bundle of measures. Resuscitation 2016; 106:1-6. Medline
I Neutral (Yellow) Survival Patient PH-Paramedic Bohn A., Weber TP., Wecker S., Harding U., Osada N., Van Aken H., et al. The addition of voice prompts to audiovisual feedback and debriefing does not modify CPR quality or outcomes in out of hospital cardiac arrest--a prospective, randomized trial. Resuscitation 2011; 82(3):257-62. Medline
I Neutral (Yellow) ROSC Patient PH-Paramedic Hostler D., Everson-Stewart S., Rea TD., Stiell IG., et al. Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: prospective cluster-randomized trial. BMJ 20011; 342d512. Medline
II Supportive (Green) CPR quality Process Guenther SPW., Schirren M., Boulesteix AL., Busen H., Poettinger T., Pichlmaier AM., et al. Effects of the Cardio First AngelTM on chest compression performance. Technology and health care 2018; 26(1):69-80. Medline
II Supportive (Green) Median chest compression rates Process PH-Paramedic Kennedy J, Machado K, Maynard C, Walker RG, Sayre MR, Counts CR. Metronome use improves achievement of a target compression rate in out-of-hospital cardiac arrest: A retrospective analysis. Resusc Plus 2023; 15:100417. Medline
II Supportive (Green) CPR quality - depth, etc. Process PH-Paramedic Kramer-Johansen J., et al. Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study. Resuscitation 2006; 71(3):283-92. Medline
II Supportive (Green) CPR quality Process PH-Paramedic Weston BW, Jasti J, Lerner EB, Szabo A, Aufderheide TP, Colella MR. Does an individualized feedback mechanism improve quality of out-of-hospital CPR? Resuscitation 2017; 113:96-100. Medline
II Neutral (Yellow) ROSC, 24 hour survival Patient Botelho RM, Campanharo CR, Lopes MC, Okuno MF, Gois AF, Batista RE. The use of a metronome during cardiopulmonary resuscitation in the emergency room of a university hospital. Rev Lat Am; 24:e2829. Medline
II Neutral (Yellow) accuracy of simulated CPR sessions Process SIM Musiari M, Saporito A, Ceruti S, Biggiogero M, Iattoni M, Glotta A, et al. Can a Glove-Coach Technology Significantly Increase the Efficacy of Cardiopulmonary Resuscitation on Non-healthcare Professionals? A Controlled Trial. Front Cardiovasc Med 2021; 8:685988. Medline
II Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Sood N, Sangari A, Goyal A, et al. Do cardiopulmonary resuscitation real-time audiovisual feedback devices improve patient outcomes? A systematic review and meta-analysis. World J Cardiol October 2023; 15(10):531-41. Medline
III Supportive (Green) CPR quality Process PH-Paramedic Fletcher D., et al. Basics in advanced life support: A role for download audit and metronomes. Resus 2008; 78:127-34. Medline
III Supportive (Green) CPR feedback device improves CPR Process Other Jaskuła J, Stolarz-Skrzypek K, Jaros K, Wordliczek J, Cebula G, Kloch M. Improvement in paramedics chest compression quality with use of real-time feedback device: Randomized trial. Kardiol Pol 2023. Medline
III Supportive (Green) Quality of CPR rate and depth Process SIM Skorning M., Beckers SK., Brokmann JC., et al. New visual feedback device improves performance of chest compressions by professionals in simulated cardiac arrest. Resuscitation 2010; 81(1):53-58. Medline
III Supportive (Green) Mean correct rate and depth of compressions Process SIM Skorning M., Derwall M., Brokmann JC., et al. External chest compressions using a mechanical feedback device: Cross-over simulation study. Anaesthesist 2011; 60(8):717-722. Medline
III Supportive (Green) Percentage of chest compressions with both correct rate and correct depth Process Wutzler A., von Ulmenstein S., Bannehr M., Valk K., Farster J., Storm C., et al. Improvement of lay rescuer chest compressions with a novel audiovisual feedback device : A randomized trial. Med Klin Intensivmed Notfmed 2018; 113(2):124-130. Medline
III Neutral (Yellow) No flow ratio Process PH-Paramedic Stecher FS., Olsen JA., Stickney RE., Wik L. Transthoracic impedance used to evaluate performance of CPR during OOHCA. Resus 2008; 79:432-7. Medline
X Not Yet Graded (White) - Gerber S, Pourmand A, Sullivan N, Shapovalov V. Ventilation assisted feedback in out of hospital cardiac arrest. Am J Emerg Med 2023; 74:198.e1-5. Medline
X Not Yet Graded (White) - Lee ED, Jang YD, Kang JH, et al. Effect of a Real-Time Audio Ventilation Feedback Device on the Survival Rate and Outcomes of Patients with Out-of-Hospital Cardiac Arrest: A Prospective Randomized Controlled Study. J Clin Med Sept 2023; 12(18). Medline

Critical care life support
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Any patient-focused outcome Patient von Vopelius-Feldt J., Brandling J., Benger J. Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest. Resuscitation 2017; 114:40-6. Medline

Dispatch assisted CCC
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival Patient PH-Paramedic Hupfl M., Selig HF., Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: A meta-analysis. Lancet 2010; 376(9752):1552-7. Medline
I Supportive (Green) 30 day survival Patient PH-Paramedic Svensson L., et al. Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest. NEJM 2010; 363:434-442. Medline
I Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Hallstrom AP. Dispatcher-assisted "phone" cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. Crit Care Med 2000; 28(S11):N190-2. Medline
II Supportive (Green) Favourable neurological outcome Patient PH-Paramedic Japanese Circulation Society Resuscitation Science Study Group. Chest-compression-only bystander cardiopulmonary resuscitation in the 30:2 compression-to-ventilation ratio era. nationwide observational study. Circ J 2013; 77(11):2742-50. Medline
II Supportive (Green) Discharge from hospital with favourable neuro Patient PH-Paramedic Olasveengen TM., Wik L., Steen PA. Standard basic life support vs. continuous chest compressions only in out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2008; 52(7):914-9. Medline
III Supportive (Green) Chest compression rate and depth Process SIM Dias JA., Brown TB., Saini D., et al. Simplified dispatch-assisted CPR instructions outperform standard protocol. Resuscitation 2007; 72(1):108-14. Medline
III Supportive (Green) Time to first compression Process SIM Williams JG., Brice JH., De Maio VJ., Jalbuena T. A simulation trial of traditional dispatcher-assisted CPR versus compressions--only dispatcher-assisted CPR. Prehosp Emerg Care 2006; 10(2):247-253. Medline
III Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Rea TD., Fahrenbruch C., Culley L., Donohoe RT., Hambly C., Innes J., et al. CPR with chest compression alone or with rescue breathing. N Engl J Med 2010; 363(5):423-33. Medline

Dispatcher video assistance
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Favorable neurologic outcome Patient PH-Bystander HS L, You K, JP J, Kim C, Kim S. The effect of video-instructed versus audio-instructed dispatcher-assisted cardiopulmonary resuscitation on patient outcomes following out of hospital cardiac arrest in Seoul. Sci Rep 2021; 11(1):15555. Medline
III Supportive (Green) Adequate hand placement during chest compressions. Process SIM Won Lee SG, Kim TH, Lee HS, Shin SD, Song KJ, Hong KJ, Kim JH, et al. Efficacy of a new dispatcher-assisted cardiopulmonary resuscitation protocol with audio call-to-video call transition. Am J Emerg Med 2021; 44:26–32. Medline
X Not Yet Graded (White) - Aranda-García S, Barrio-Cortes J, Fernández-Méndez F, et al. Dispatcher-assisted BLS for lay bystanders: A pilot study comparing video streaming via smart glasses and telephone instructions. Am J Emerg Med 2023; 71:163-8. Medline

Early epinephrine
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) 30-day survival Patient Fukuda T., Kondo Y., Hayashida K., Sekiguchi H., Kukita I. Time to epinephrine and survival after paediatric out-of-hospital cardiac arrest. European heart journal Cardiovascular pharmacotherapy. Eur Heart J Cardiovasc Pharmacother 2018; 4(3):144-51. Medline
II Supportive (Green) Survival to hospital discharge Patient Hansen M., Schmicker RH., Newgard CD., Grunau B., Scheuermeyer F., Cheskes S., et al. Time to Epinephrine Administration and Survival from Non-Shockable Out-of-Hospital Cardiac Arrest Among Children and Adults. Circulation 2018; 137(19):2032-40. Medline
II Supportive (Green) Survival to discharge Patient PH-Paramedic Okubo M, Komukai S, Callaway CW, Izawa J. Association of Timing of Epinephrine Administration With Outcomes in Adults With Out-of-Hospital Cardiac Arrest. JAMA Netw Open 2021; 4(8):e2120176. Medline
II Supportive (Green) Favorable cerebral function Patient Sagisaka R., Tanaka H., Takyu H., Ueta H., Tanaka S. Effects of repeated epinephrine administration and administer timing on witnessed out-of-hospital cardiac arrest patients. Am J Emerg Med 2017; 35(10):1462-8. Medline
II Supportive (Green) Rate of a good prognosis for cerebral performance (CPC 1-2) Patient Ueta H., Tanaka H., Tanaka S., Sagisaka R., Takyu H. Quick epinephrine administration induces favorable neurological outcomes in out-of-hospital cardiac arrest patients. Am J Emerg Med 2017; 35(5):676-680. Medline
II Neutral (Yellow) Dosing interval; 1-month neurological status Patient PH-Paramedic Fukuda T, Kaneshima H, Matsudaira A, Chinen T, Sekiguchi H, Ohashi-Fukuda N, et al. Epinephrine dosing interval and neurological outcome in out-of-hospital cardiac arrest. Perfusion 2021; 2676591211025163. Medline
X Not Yet Graded (White) - Okubo M, Komukai S, Izawa J, et al. Sequence of Epinephrine and Advanced Airway Placement After Out-of-Hospital Cardiac Arrest. JAMA Netw Open February 2024; 7(2):e2356863. Medline

ECG
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) Prediction of survival to hospital discharge Patient PH-Paramedic Ho ML., Gatien M., Vaillancourt C., Whitham V., Stiell IG. Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests. EMJ 2018; 35(2) 89-95. Medline

EMS provided CCC
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival to hospital discharge Patient PH-Paramedic Nichol G., Leroux B., Wang H., et al. Trial of continuous or interrupted chest compressions during CPR. N Engl J Med 2015; 373(23):2203-14. Medline
I Supportive (Green) Survival to discharge Process PH-Paramedic XN Qin, Han MX, Lim YL, Arulanandam S. A Systematic Review and Meta-Analysis of the Implementation of High-Performance Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest Outcomes. J Clin Med 2021; 10(10). Medline
II Supportive (Green) Survival-to-hospital discharge Patient PH-Paramedic Bobrow BJ., Clark LL., Ewy GA., et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA 2008; 299(10):1158-65. Medline
II Supportive (Green) Survival Patient PH-Paramedic Brouwer TF., Walker RG., Chapman FW., Koster RW. Association between chest compression interruptions and clinical outcomes of ventricular fibrillation out-of-hospital cardiac arrest. Circulation 2015; 132(11):1030-7. Medline
II Supportive (Green) ROSC Patient PH-Paramedic Lee IH., How CK., Lu WH., et al. Improved survival outcome with continuous chest compressions with ventilation compared to 5:1 compressions-to-ventilations mechanical cardiopulmonary resuscitation in out-of-hospital cardiac arrest. J Chin Med Assoc 2013; 76(3):158-63. Medline
II Neutral (Yellow) Survival from OHCA Patient PH-Paramedic Schmicker RH, Nichol G, Kudenchuk P, Christenson J, Vaillancourt C, Wang HE, et al. CPR compression strategy 30:2 is difficult to adhere to, but has better survival than continuous chest compressions when done correctly. Resuscitation 2021; 165:31–7. Medline

Epinephrine
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival to Admission Patient ED-Paramedic & MD Fernando SM, Mathew R, Sadeghirad B, Rochwerg B, et al. Epinephrine in Out-of-Hospital Cardiac Arrest: A Network Meta-analysis and Subgroup Analyses of Shockable and Nonshockable Rhythms. Chest August 2023; 164(2):381-393. Medline
I Supportive (Green) ROSC Process PH-Paramedic Gueugniaud PY., Mols P., Goldstein P., et al. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European epinephrine study group. N Engl J Med 1998; 339(22):1595-601. Medline
I Supportive (Green) Survival at 30 days Patient Perkins GD., Ji C., Deakin CD., Quinn T., et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med 2018; 379(8):711-721. Medline
I Neutral (Yellow) 6 month survival Patient PH-Paramedic & MD Haywood KL, Ji C, Quinn T, Nolan JP, Deakin CD, Scomparin C, et al. Long term outcomes of participants in the PARAMEDIC2 randomised trial of adrenaline in out-of-hospital cardiac arrest. Resuscitation 2021; 160:84-93. Medline
I Neutral (Yellow) Survival to hospital d/c Patient PH-Paramedic Jacobs IG., Finn JC., Jelinick GA., Oxer HF., Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomized, double-blind, placebo-controlled trial. Resusc 2011; 82(9)1138-43. Medline
I Neutral (Yellow) Survival to discharge Patient PH-Paramedic Lin S., Callaway CW., Shah PS., et al. Adrenaline for out-of-hospital cardiac arrest resuscitation: A systematic review and meta-analysis of randomized controlled trials. Resuscitation 2014; 85(6):732-740. Medline
I Neutral (Yellow) Survival to hospital discharge Patient ED-MD Ong ME., Tiah L., Leong BS., et al. A randomised, double-blind, multi-centre trial comparing vasopressin and adrenaline in patients with cardiac arrest presenting to or in the emergency department. Resuscitation 2012; 83(8):953-60. Medline
I Neutral (Yellow) ROSC Patient ED-MD Sillberg VAH., Perry JJ., Stiell IG., Wells GA. Is the combination of vasopressin and epinephrine superior to repeated doses of epi alone in the treatment of cardiac arrest - a systematic review. Resus 2008; 79:380-6. Medline
I Neutral (Yellow) Survival to hospital admission Patient PH-Paramedic Wenzel V., Krismer AC., et al. A Comparison of Vasopressin and Epinephrine for Out-of-Hospital Cardiopulmonary Resuscitation. New Engl J Med 2003; 350(2):105-13. Medline
I Neutral (Yellow) Survival to discharge, neurological function Patient PH-Paramedic Wyer PC., et al. Vasopressin or Epinephrine for Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2006; 48(1):86-97. Medline
I Neutral (Yellow) Efficacy (ROSC rate) Patient Zhang Q., Liu B., Zhao L., Qi Z., Shao H., An L., et al. Efficacy of vasopressin-epinephrine compared to epinephrine alone for out of hospital cardiac arrest patients: A systematic review and meta-analysis. Am J Emerg Med 2017; 35(10):1555-60. Medline
I Neutral (Yellow) Survival to discharge Patient PH-Paramedic Zhong H, Yin Z, Kou B, et al. Therapeutic and adverse effects of adrenaline on patients who suffer out-of-hospital cardiac arrest: a systematic review and meta-analysis. Eur J Med Res 2023; 28(1):24. Medline
II Supportive (Green) Efficacy Patient PH-Paramedic & MD Hou M, Dong S, Kan Q, Ouyang M, Zhang Y. Is epinephrine still the drug of choice during cardiac arrest in the emergency department of the hospital? A meta-analysis. Acta Pharm Sept 2023; 73(3):325-39. Medline
II Supportive (Green) 1-month survival Patient PH-Paramedic Matsuyama T, Komukai S, Izawa J, Gibo K, Okubo M, Kiyohara K, et al. Epinephrine administration for adult out-of-hospital cardiac arrest patients with refractory shockable rhythm: time-dependent propensity score-sequential matching analysis from a nationwide population-based registry. Eur Heart J Cardiovasc Pharmacother 2021. Medline
II Supportive (Green) Neurologically intact survival. Patient Tomio J., Nakahara S., Takahashi H., Ichikawa M., Nishida M., Morimura N., et al. Effectiveness of Prehospital Epinephrine Administration in Improving Long-term Outcomes of Witnessed Out-of-hospital Cardiac Arrest Patients with Initial Non-shockable Rhythms. Prehosp Emerg Care 2017; 21(4):432-441. Medline
II Neutral (Yellow) ROSC on ED arrival Process PH-Paramedic Carvolth RD., Hamilton AJ. Comparison of high-dose epinephrine versus standard-dose epinephrine in adult cardiac arrest in the prehospital setting. Prehosp Disaster Med 1996; 11(3):219-22. Medline
II Neutral (Yellow) Survival to hospital discharge Patient Fisk CA., Olsufka M., Yin L., McCoy AM., Latimer AJ, Maynard C, et al. Lower-dose epinephrine administration and out-of-hospital cardiac arrest outcomes. Resuscitation 2018; 124:43-8. Medline
II Neutral (Yellow) Favourable CPC scores post-OHCA survival at 30 days. Patient PH-Paramedic Fukuda T, Kaneshima H, Matsudaira A, Chinen T, Sekiguchi H, Ohashi-Fukuda N, et al. Epinephrine dosing interval and neurological outcome in out-of-hospital cardiac arrest. Perfusion 2021; 2676591211025163. Medline
II Neutral (Yellow) Survival to discharge Patient PH-Paramedic Ong MEH., et al. Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest. Ann Emerg Med 2007; 50:635-42. Medline
II Neutral (Yellow) Incidence of re-arrest Patient ED-MD Sharpe AR, Richardson K, Stanton M, et al. Lack of Association of Initial Vasopressor Dosing with Survival and Cardiac Re-Arrest Likelihood After Return of Spontaneous Circulation. J Emerg Med Sept 2023; 65(3):e209-20. Medline
II Opposes (Red) Survival to discharge neurologically intact Patient PH-Paramedic Dumas F., Bougouin W., Geri G., et al. Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients? J Am Coll Cardiol 2014; 64(22):2360-7. Medline
II Opposes (Red) Favourable neurological outcome Patient PH-Paramedic Fukuda T., Fukuda-Ohashi N., Doi K., Matsubara T., Yahagi N. Effective pre-hospital care for out-of-hospital cardiac arrest caused by respiratory disease. Heart Lung Circ 2015; 24(3):241-9. Medline
II Opposes (Red) Neurologically intact (CPC1-2) survival at 1-month Patient Fukuda T., Ohashi-Fukuda N., Matsubara T., Gunshin M., Kondo Y., Yahagi N. Effect of prehospital epinephrine on out-of-hospital cardiac arrest: a report from the national out-of-hospital cardiac arrest data registry in Japan, 2011-2012. Eur J Clin Pharmacol 2016; 72(10):1255-64. Medline
II Opposes (Red) Survival to hospital discharge Patient PH-Paramedic & CCT Goto Y., Maeda T., Goto YN. Effects of prehospital epinephrine during out-of-hospital cardiac arrest with initial non-shockable rhythm: An observational cohort study. Crit Care 2013; 17(5):R188. Medline
II Opposes (Red) Survival Patient ED-MD Hagihara A., Manabu H., Takeru A., Takashi N., Yoshifumi W., Shogo M. Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest. JAMA 2012; 307(11):1161-8. Medline
II Opposes (Red) Survival to discharge Patient PH-Paramedic Han E, Kong T, You JS, Park I, Park G, Lee S, Chung SP; Korean Cardiac Arrest Research Consortium (KoCARC) Investigators. Effect of Prehospital Epinephrine on Out-of-Hospital Cardiac Arrest Outcomes: A Propensity Score-Matched Analysis. Yonsei Med J 2022; 63(2):187–94. Medline
II Opposes (Red) Transitions from ROSC to VF/VT Patient PH-Paramedic Neset A., Nordseth T., Kramer-Johansen J., Wik L., Olasveengen TM. Effects of adrenaline on rhythm transitions in out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2013; 57(10):1260-7. Medline
II Opposes (Red) ROSC Patient PH-Paramedic Niemann J., Stratton S. Endotracheal versus intravenous epinephrine and atropine in out-of-hospital "primary" and post countershock asystole. Critical Care Medicine 2000; 26(6):1815-9. Medline
II Opposes (Red) Survival to DC Patient PH-Paramedic Olasveengen TM., Wik L., Sunde K., Steen PA. Outcome when adrenaline (epinephrine) was actually given vs. not given - post hoc analysis of a randomized clinical trial. Resuscitation 2012; 83(3):327-32. Medline
III Supportive (Green) Survival Patient ED-MD Larabee TM., Liu KY., Campbell JA., Little CM. Vasopressors in cardiac arrest: A systematic review. Resuscitation 2012; 83(8):932-9. Medline
III Neutral (Yellow) Sustained ROSC Patient Lindner KH., Ahnefeld FW., Grunert A. Epinephrine versus norepinephrine in prehospital ventricular fibrillation. Am J Cardiol 1991; 67(5):427-8. Medline
III Neutral (Yellow) Survival to DC Patient PH-Paramedic Olasveengen TM., Sunde K., Brunborg C., Thowsen J., Steen PA., Wik L. Intravenous drug administration during out-of-hospital cardiac arrest: A randomized trial. JAMA 2009; 302(20):2222-9. Medline
III Neutral (Yellow) Survival Patient ED-MD Stiell IG., Hebert PC., Wells GA., et al. Vasopressin versus epinephrine for in-hospital cardiac arrest: a randomised controlled trial. Lancet 2001; 358(9276):105-9. Medline
III Neutral (Yellow) Survival time Patient PH-Paramedic Wang HE., Min A., Hostler D., Chang CC., Callaway CW. Differential effects of out-of-hospital interventions on short- and long-term survival after cardiopulmonary arrest. Resuscitation 2005; 67(1):69-74. Medline
III Opposes (Red) Survival to discharge Process Other Ahn S, BY J, Cho H, Moon S, Cho YD, Park JH. Association of prehospital advanced airway and epinephrine with survival in patients with out-of-hospital cardiac arrest. Sci Rep October 2023; 13(1):17836. Medline

ETCO2 evaluation of ventilation
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Feasibility Process Aramendi E, Elola A, Alonso E, Irusta U, Daya M, Russell JK, et al. Feasibility of the capnogram to monitor ventilation rate during cardiopulmonary resuscitation. Resuscitation 2017; 110:162-8. Medline

ETCO2 for compression evaluation
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) ETCO2 Process PH-Paramedic Gutiérrez JJ, Sandoval CL, Leturiondo M, Russell JK, Redondo K, et al. Contribution of chest compressions to end-tidal carbon dioxide levels generated during out-of-hospital cardiopulmonary resuscitation. Resuscitation 2022. Medline
II Supportive (Green) Sustained ROSC Patient PH-Paramedic Kolar M., Križmarić M., Klemen P., Grmec S. Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study. Critical Care 2008; 12:5. Medline
II Supportive (Green) Association between EtCO2 and CPR quality Process Murphy RA., Bobrow BJ., Spaite DW., Hu C., McDannold R., Vadeboncoeur TF. Association between Prehospital CPR Quality and End-Tidal Carbon Dioxide Levels in Out-of-Hospital Cardiac Arrest. Prehospital Emergency Care 2016; 20(3):369-77. Medline
III Supportive (Green) Effective defib Process Savastano S., Baldi E., Raimondi M., Palo A., Belliato M., Cacciatore E., et al. End-tidal carbon dioxide and defibrillation success in out-of-hospital cardiac arrest. Resuscitation 2017; 121:71-5. Medline
III Supportive (Green) ROSC Patient PH-Paramedic White RD., Goodman BW., Svoboda MA. Neurologic recovery following prolonged out-of-hospital cardiac arrest with resuscitation guided by continuous capnography. Mayo Clin Proc 2011; 86(6):544-548. Medline
III Neutral (Yellow) Sensitivity and Specificity Process Lui CT., Poon KM., Tsui KL. Abrupt rise of end tidal carbon dioxide level was a specific but non-sensitive marker of return of spontaneous circulation in patient with out-of-hospital cardiac arrest. Resuscitation 2016; 104:53-8. Medline

ETCO2 to determine ROSC
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) ROSC Patient Singer AJ., Nguyen RT., Ravishankar ST., Schoenfeld ER., Thode HC., Henry MC., et al. Cerebral oximetry versus end tidal CO2in predicting ROSC after cardiac arrest. Am J Emerg Med 2018; 36(3):403-7. Medline
II Supportive (Green) Predictive value Patient PH-Paramedic Crickmer M, Drennan IR, Turner L, Cheskes S. The association between end-tidal CO2 and return of spontaneous circulation after out-of-hospital cardiac arrest with pulseless electrical activity. Resuscitation 2021; 167:76–81. Medline
II Supportive (Green) Prediction of ROSC Process PH-Paramedic Gutiérrez JJ, Leturiondo M, Ruiz de Gauna S, Ruiz JM, Azcarate I, González-Otero DM, Urtusagasti JF, Russell JK, Daya MR. Assessment of the evolution of end-tidal carbon dioxide within chest compression pauses to detect restoration of spontaneous circulation. PLoS One. 2021 May 18;16(5):e0251511. doi: 10.1371/journal.pone.0251511. PMID: 34003839; PMCID: PMC8130954. Medline
II Supportive (Green) Predictor of ROSC Patient PH-Paramedic Hubble MW, Van Vleet L, Taylor S, Bachman M, Williams JG, Vipperman R, et al. Predictive Utility of End-Tidal Carbon Dioxide on Defibrillation Success in Out-of-Hospital Cardiac Arrest. PEC 2020:1-13. Medline
II Neutral (Yellow) Association between ETCO2 and survival Process PH-Paramedic Dennis M. Out-of-hospital cardiac arrest outcomes, end-tidal carbon dioxide and extracorporeal cardiopulmonary resuscitation eligibility: New South Wales pilot data. Emerg Med Australas 2022; 34(3):452–5. Medline
II Neutral (Yellow) Post shock change in EtCO2 Patient PH-Paramedic Grabman B, Bulger NE, Harrington BM, Walker RG, Latimer AJ, Snyder BD, Sayre MR, Maynard C, Johnson NJ, Van Dyke M, Counts CR.Increase in end-tidal carbon dioxide after defibrillation predicts sustained return of spontaneous circulation during out-of-hospital cardiac arrest. Resuscitation 2022; 181:48–54. Medline
II Neutral (Yellow) Indication of ROSC Process Other Nicholson TC, Paiva EF. Uses and pitfalls of measurement of end-tidal carbon dioxide during cardiac arrest. Curr Opin Crit Care 2020; 26(6):612-6. Medline
III Supportive (Green) Predictor of ROSC Patient Other Javaudin F, Her S, Le Bastard Q, De Carvalho H, Le Conte P, Baert V, Hubert H, Montassier E, Lascarrou JB, Leclère B; GR-RéAC. Maximum Value of End-Tidal Carbon Dioxide Concentrations during Resuscitation as an Indicator of Return of Spontaneous Circulation in out-of-Hospital Cardiac Arrest. Prehosp Emerg Care. 2020 Jul-Aug;24(4):478-484. doi: 10.1080/10903127.2019.1680782. Epub 2019 Oct 31. PMID: 31613696. Medline

ETCO2 to guide termination
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Detection of Survival to Discharge Patient PH-Paramedic Hambelton C, Wu L, Smith J, et al. Utility of end-tidal carbon dioxide to guide resuscitation termination in prolonged out-of-hospital cardiac arrest. Am J Emerg Med 2023; 77:77-80. Medline

ETT Drug Admin.
Level Direction Primary Outcome Patient/Process Setting Reference
II Opposes (Red) ROSC Patient PH-Paramedic Niemann JT., Stratton SJ., Cruz B., Lewis RJ. Endotracheal drug administration during out-of-hospital resuscitation: Where are the survivors? Resuscitation 2002; 53(2):153-7. Medline
III Neutral (Yellow) Time required Process SIM Mielke LL., Lanzinger MJ., Entholzner EK., Hargasser SR., Hipp RF. The time required to perform different methods for endotracheal drug administration during CPR. Resuscitation 1999; 40(3):165-9. Medline

Family Involvement in Resuscitation
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Patient preference Patient In-Patient Albarran J., Moule P., Benger J., McMahon-Parkes K., Lockyer L. Family witnessed resuscitation: The views and preferences of recently resuscitated hospital inpatients, compared to matched controls without the experience of resuscitation survival. Resuscitation 2009; 80(9):1070-3. Medline
III Supportive (Green) Effects on patient care Patient Youngson MJ., Currey J., Considine J. Family presence during management of acute deterioration: Clinician attitudes, beliefs and perceptions of current practices. Australas Emerg Nurs J 2016; 19(3):159-65. Medline
X Not Yet Graded (White) - Afzali Rubin M, Svensson TL, Herling SF, Jabre P, Møller AM. Family presence during resuscitation. Cochrane Database Syst Rev 2023; 5(5):CD013619. Medline

Fibrinolysis
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Abu-Laban RB., et al. TPA in Cardiac Arrest with Pulseless Electrical Activity. NEJM 2002; 346: 1522-8. Medline
I Neutral (Yellow) 30 day survival. Patient PH-Paramedic Bottiger BW., Arntz HR., Chamberlain DA., et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 2008; 359(25):2651-62. Medline
II Supportive (Green) ROSC Patient ED-MD Bottiger BW., Bode C., Kern S., Gries A., Gust R., Glatzer R., et al. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: A prospective clinical trial. Lancet 2001; 357(9268):1583-5. Medline
II Neutral (Yellow) Hospital discharge Patient PH-Paramedic Stadlbauer KH., Krismer AC., Arntz HR., Mayr VD., Lienhart HG., Bottiger BW., et al. Effects of thrombolysis during out-of-hospital cardiopulmonary resuscitation. Am J Cardiol 2006; 97(3):305-308. Medline
III Supportive (Green) Survival to discharge Patient Arntz HR., Wenzel V., Dissmann R., Marschalk A., Breckwoldt J., Muller D. Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood of ST-elevation myocardial infarction. Resuscitation 2008; 76(2):180-4. Medline
III Supportive (Green) ROSC Process Duchateau FX., Preiss V., Ricard-Hibon A., Chollet C., Marty J. Out-of-hospital thrombolytic therapy during cardiopulmonary resuscitation in refractory cardiac arrest due to acute myocardial infarction. Eur J Emerg Med 2001; 8(3):241-3. Medline
III Supportive (Green) Neurological outcome Patient PH-Paramedic Lederer W., Lichtenberger C., Pechlaner C., Kinzl J., Kroesen G., Baubin M. Long-term survival and neurological outcome of patients who received r-TPA during out-of-hospital cardiac arrest. Resuscitation 2004; 61:123-9. Medline
III Supportive (Green) Myocardial reperfusion Patient PH-Paramedic Voipio V., Kuisma M., Alaspaa A., Manttari M., Rosenberg P. Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest. Resuscitation 2001; 49(3):251-258. Medline
III Neutral (Yellow) ROSC Process PH-Paramedic Fatovich DM., Dobb GJ., Clugston RA. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation 2004; 61:309-13. Medline
III Neutral (Yellow) ROSC Patient ED-MD Pyo SY, Park GJ, Kim SC, Kim H, Lee SW, Lee JH. Return of spontaneous circulation in patients with out-of-hospital cardiac arrest caused by pulmonary embolism using early point-of-care ultrasound and timely thrombolytic agent application: Two case reports. Hong Kong J of Emerg Med 2020 Medline
III Opposes (Red) Adverse event Patient ICU Fraipont V., Peters JL., Weber T., et al. Heart enlargement after thrombolysis for unsuccessful resuscitation. Intensive Care Med 2003; 29(3):507-8. Medline

Fluid Resuscitation
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Survival Patient Nongchang P., Wong WL., Pitaksanurat S., Amchai PB. Intravenous Fluid Administration and the Survival of Pre hospital Resuscitated out of Hospital Cardiac Arrest Patients in Thailand. J Clin Diagn Res 2017; 11(9):OC29-OC32. Medline

Head-up CPR
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Survival Process PH-Paramedic Moore JC, Pepe PE, Scheppke KA, Lick C, Duval S, Holley J, Salverda B, Jacobs M, Nystrom P, Quinn R, Adams PJ, Hutchison M, Mason C, Martinez E, Mason S, Clift A, Antevy PM, Coyle C, Grizzard E, Garay S, Crowe RP, Lurie KG, Debaty GP, Labarère J. Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Resuscitation. 2022 Oct;179:9-17. doi: 10.1016/j.resuscitation.2022.07.039. Epub 2022 Aug 4. PMID: 35933057. Medline
III Supportive (Green) Variation in near-infrared spectroscopy Process ED-MD Kim DW, Choi JK, Won SH, Yun YJ, Jo YH, Park SM, Lee DK, Jang DH. A new variant position of head-up CPR may be associated with improvement in the measurements of cranial near-infrared spectroscopy suggestive of an increase in cerebral blood flow in non-traumatic out-of-hospital cardiac arrest patients: A prospective interventional pilot study. Resuscitation. 2022 Jun;175:159-166. doi: 10.1016/j.resuscitation.2022.03.032. Epub 2022 Apr 5. PMID: 35395338. Medline

High Dose Epi.
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) ROSC Patient PH-Paramedic Fernando SM, Mathew R, Sadeghirad B, Rochwerg B, et al. Epinephrine in Out-of-Hospital Cardiac Arrest: A Network Meta-analysis and Subgroup Analyses of Shockable and Nonshockable Rhythms. Chest August 2023; 164(2):381-393. Medline
I Supportive (Green) ROSC Process PH-Paramedic Gueugniaud PY., Mols P., Goldstein P., et al. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European epinephrine study group. N Engl J Med 1998; 339(22):1595-601. Medline
I Supportive (Green) ROSC Patient ED-MD Lindner K., Ahnefeld F., Prengel W. Comparison of standard and high-dose adrenaline in the resuscitation of asystole and electromechanical dissociation. Acta Anaesthesiol Scand 1991; 35:253-6. Medline
I Neutral (Yellow) ROSC, Survival to discharge, Neuro outcomes Patient PH-Paramedic Callaham M., Madsen C., Barton C., et al. A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest. JAMA 1992; 268:2667-72. Medline
I Neutral (Yellow) Improvement in cardiac rhythm or ROSC Patient ED-MD Sherman B., Munger M., Foulke G., et al. High-dose versus standard-dose epinephrine treatment of cardiac arrest after failure of standard therapy. Pharmacotherapy 1997; 17:242-247. Medline
II Neutral (Yellow) ROSC on ED arrival Process PH-Paramedic Carvolth RD., Hamilton AJ. Comparison of high-dose epinephrine versus standard-dose epinephrine in adult cardiac arrest in the prehospital setting. Prehosp Disaster Med 1996; 11(3):219-22. Medline
II Opposes (Red) AKI post ROSC. Patient ICU Gao Q, Mok HP, Qiu HL, Cen J, Chen J, Zhuang J. Accumulated Epinephrine Dose is Associated With Acute Kidney Injury Following Resuscitation in Adult Cardiac Arrest Patients. Front Pharmacol 2022; 13:806592. Medline
III Supportive (Green) Prediction of transfusion needs Process PH-Paramedic Larabee TM., Liu KY., Campbell JA., Little CM. Vasopressors in cardiac arrest: A systematic review. Resuscitation 2012; 83(8):932-9. Medline
III Neutral (Yellow) ROSC Patient PH-Paramedic Brown C., Martin D., Pepe P., et al. A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. N Engl J Med 1992; 327:1051-5. Medline

Hypertonic Saline
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Admission to hospital with spontaneous circulation Patient PH-Paramedic Breil M., Krep H., Heister U., et al. Randomised study of hypertonic saline infusion during resuscitation from out-of-hospital cardiac arrest. Resuscitation 2012; 83(3):347-52. Medline
II Supportive (Green) Admission to hospital with spontaneous circulation Process Hahn C., Breil M., Christian J., et al. Hypertonic saline infusion during resuscitation from out-of-hospital cardiac arrest: A matched-pair study from the German Resuscitation Registry . Resuscitation 2014; 8(5):628–36. Medline
III Neutral (Yellow) ROSC Process PH-Paramedic Bender R., Breil M., Heister U., et al. Hypertonic saline during CPR: Feasibility and safety of a new protocol of fluid management during resuscitation. Resuscitation 2007; 72: 74-81. Medline

Impedance Threshold Device
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival to ICU Patient Aufderheide TP., Pirrallo RG., Provo TA., Lurie KG. Clinical evaluation of an inspiratory impedance threshold device during standard cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest. Crit Care Med 2005; 33(4)734-40. Medline
I Supportive (Green) Survival, Favourable neurological outcome, ROSC Patient PH-Paramedic Cabrini L., Beccaria P., Landoni G., Biondi-Zoccai GG., Sheiban I., Cristofolini M., et al. Impact of impedance threshold devices on cardiopulmonary resuscitation: a systematic review and meta-analysis of randomized controlled studies. Crit Care Med 2008; 36(5):1625-32. Medline
I Supportive (Green) Blood pressure Patient ED-MD Pirrallo RG., Aufderheide TP., Provo TA., Lurie KG. Effect of an inspiratory impedance threshold device on hemodynamics during conventional manual cardiopulmonary resuscitation. Resuscitation 2005; 66(1):13-20. Medline
I Supportive (Green) Intrathoracic pressure Patient ED-MD Plaisance P., Soliel C., Lurie KG., Vicault E., et al. Use of an inspiratory impedance threshold device on facemask and endotracheal tube to reduce intrathoracic pressures during the decompression phase of active compression-decompression cardiopulmonary resuscitation. Crit Care Med 2005; 33(5):990-4. Medline
I Neutral (Yellow) Neuro intact survival Patient PH-Paramedic Aufderheide TP., Nichol G., Rea TD., Brown SP., Leroux BG., Pepe PE., et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med 2011; 365(9):798-806. Medline
I Neutral (Yellow) ROSC Patient PH-Paramedic Wang CH., Tsai MS., Chang WT., et al. Active compression-decompression resuscitation and impedance threshold device for out-of-hospital cardiac arrest: A systematic review and metaanalysis of randomized controlled trials. Crit Care Med 2015; 43(4):889-896. Medline
II Supportive (Green) Accuracy Process Kwok H., Coult J., Liu C., Blackwood J., Kudenchuk PJ., Rea TD., et al. An accurate method for real-time chest compression detection from the impedance signal. Resuscitation 2016; 105:22-8. Medline
II Supportive (Green) Survived with favorable neurological outcomes Patient Sugiyama A., Duval S., Nakamura Y., Yoshihara K., Yannopoulos D. Impedance Threshold Device Combined With High-Quality Cardiopulmonary Resuscitation Improves Survival With Favorable Neurological Function After Witnessed Out-of-Hospital Cardiac Arrest. Circ J 2016; 80(10):2124-32. Medline
X Not Yet Graded (White) - Magliocca A, Castagna V, Fornari C, et al. Transthoracic impedance variability to assess quality of chest compression in out-of-hospital cardiac arrest. Acta Anaesthesiol Scand January 2024. Medline

Intra-Arrest Cooling
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Safety Process PH-Paramedic Castren M., Nordberg P., Svensson L., Taccone F., Vincent JL., Desruelles D., et al. Intra-arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness). Circulation 2010; 122(7):729-36. Medline
I Neutral (Yellow) Survival neurologically intact Patient PH-Paramedic Szarpak L, Filipiak KJ, Mosteller L, Jaguszewski M, Smereka J, Ruetzler K, et al. Survival, neurological and safety outcomes after out of hospital cardiac arrests treated by using prehospital therapeutic hypothermia: A systematic review and meta-analysis. Am J Emerg Med 2021; 42:168-77. Medline
II Supportive (Green) favourable neurological outcome Patient PH-Paramedic Taccone FS, Hollenberg J, Forsberg S, Truhlar A, Jonsson M, Annoni F, et al. Effect of intra-arrest trans-nasal evaporative cooling in out-of-hospital cardiac arrest: a pooled individual participant data analysis. Crit Care 2021; 25(1):198. Medline
II Neutral (Yellow) ROSC Process PH-Paramedic Garrett JS., Studnek JR., Blackwell T., et al. The association between intra-arrest therapeutic hypothermia and return of spontaneous circulation among individuals experiencing out of hospital cardiac arrest. Resuscitation 2011; 82(1):21-5. Medline
II Opposes (Red) Survival Patient PH-Paramedic & MD Annoni F, Peluso L, Fiore M, Nordberg P, Svensson L, Abella B, Calabro L, Scolletta S, Vincent JL, Creteur J, Taccone FS. Impact of therapeutic hypothermia during cardiopulmonary resuscitation on neurologic outcome: A systematic review and meta-analysis. Resuscitation 2021; 162:365–71. Medline
III Supportive (Green) Feasibility Process Grave MS., Sterz F., Narnberger A., Fykatas S., Gatterbauer M., Stattermayer AF., et al. Safety and feasibility of the RhinoChill immediate transnasal evaporative cooling device during out-of-hospital cardiopulmonary resuscitation: A single-center, observational study. Medicine 2016; 95(34):e4692 Medline
III Neutral (Yellow) Survival at hospital discharge Patient Bernard SA., Smith K., Finn J., Hein C., Grantham H., Bray JE., et al. Induction of Therapeutic Hypothermia During Out-of-Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline: The RINSE Trial (Rapid Infusion of Cold Normal Saline). Circulation 2016; 134(11):797-805. Medline

Intra-arrest transport (load and go)
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Survival to 30 days Patient Other Burns B, Hsu HR, Keech A, et al. Expedited transport versus continued on-scene resuscitation for refractory out-of-hospital cardiac arrest: A systematic review and meta-analysis. Resusc Plus October 2023; 16:100482. Medline
II Supportive (Green) survival Patient PH-Bystander Holmberg M., Holmberg S., Herlitz J. Factors modifying the effect of bystander CPR on survival in out-of-hospital cardiac arrest patients in Sweden. Eur Heart J 2001; 22(6):511-9. Medline
II Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Grunau B, Kime N, Leroux B, Rea T, Van Belle G, Menegazzi JJ, et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation with Survival to Hospital Discharge among Patients with Out-of-Hospital Cardiac Arrest. JAMA 2020; 324(11):1058-67. Medline

ITD and ACDC
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Neuro intact survival Patient PH-Paramedic Aufderheide TP., Frascone RJ., Wayne MA., et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: A randomised trial. Lancet 2011; 377(9762):301-11. Medline
I Supportive (Green) survival to hospital discharge with favourable neurological function Patient PH-Paramedic Frascone RJ., Wayne MA., Swor RA., et al. Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device. Resuscitation 2013; 84(9):1214-22. Medline
I Supportive (Green) 24 hour Survival Patient ED-MD Plaisance P., Lurie KG., Vicaut E., et al. Evaluation of an impedance threshold device in patients receiving active compression-decompression cardiopulmonary resuscitation for out of hospital cardiac arrest. Resuscitation 2004; 61(3):265-71. Medline
I Neutral (Yellow) ROSC Patient PH-Paramedic Wang CH., Tsai MS., Chang WT., et al. Active compression-decompression resuscitation and impedance threshold device for out-of-hospital cardiac arrest: A systematic review and metaanalysis of randomized controlled trials. Crit Care Med 2015; 43(4):889-896. Medline
II Supportive (Green) 1-hour survival after a witnessed arrest Process PH-Paramedic Wolcke BB., Mauer DK., Schoeffmann MF., Teichmann H. et al. Comparison of standard cardiopulmonary resuscitation vs the combination of active compression-decompression cardiopulmonary resuscitation and an inspiratory impedance threshold device for out-of-hospital cardiac arrest. Circ 2003; 108(18):2201-5. Medline

IV access
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) ROSC Patient PH-Paramedic Tan BKK, Chin YX, Koh ZX, Md SN, Rahmat M, Fook-Chong S, et al. Clinical evaluation of intravenous alone versus intravenous or intraosseous access for treatment of out-of-hospital cardiac arrest. Resuscitation 2021; 159:129-36. Medline
II Supportive (Green) 30-day mortality Patient PH-Paramedic Nilsson FN, Bie-Bogh S, Milling L, Hansen PM, et al. Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest. Sci Rep Nov 2023; 13(1):20796. Medline
II Neutral (Yellow) 1-month survival with favourable neurological outcome Patient Fujii T., Kitamura T., Kajino K., Kiyohara K., Nishiyama C., Nishiuchi T., et al. Prehospital intravenous access for survival from out-of-hospital cardiac arrest: propensity score matched analyses from a population-based cohort study in Osaka, Japan. BMJ open 2017; 7(12):e015055. Medline
II Neutral (Yellow) Favourable neurological outcome at hospital discharge Patient PH-Paramedic Hsieh YL, Wu MC, Wolfshohl J, d'Etienne J, Huang CH, Lu TC, et al. Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies. Scand J Trauma Resusc Emerg Med 2021; 29(1):44. Medline
II Neutral (Yellow) Success rates of establishing the access route Process PH-Paramedic Yang SC, Hsu YH, Chang YH, Chien LT, Chen IC, Chiang WC. Epinephrine administration in adults with out-of-hospital cardiac arrest: A comparison between intraosseous and intravenous route. Am J Emerg Med 2023; 67:63-9. Medline

Manual Intraosseous Insertion
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Insertion success rate Process PH-Paramedic Frascone RJ., Jensen JP., Kaye K., Salzman JG. Consecutive field trials using two different IO devices. Prehosp Emer Care 2007; 11:164-71. Medline
II Neutral (Yellow) First attempt success Patient Sunde G., Heradstveit B., Vikenes B., HeltneJ. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scan J Trauma, Resus and Emerg Med 2010; 18:52. Medline
II Opposes (Red) Neurologically favorable outcome at hospital discharge Patient Kawano T., Grunau B., Scheuermeyer FX., Gibo K., Fordyce CB., Lin S., et al. Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2018; 71(5):588-596 Medline
III Neutral (Yellow) Number of attempts required Process SIM Brenner T., Bernhard M., Helm M., Doll S., Völkl A., Ganion N., Friedmann C., Sikinger M., Knapp J., Martin E., Gries A. Comparison of two intraosseous infusion systems for adult emergency medical use. Resuscitation 2008; 78:314-9. Medline

Mechanical Intraosseous Insertion
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) First-attempt success Process PH-Paramedic Reades R., Studnek JR., Vandeventer S., Garrett J. Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: A randomized controlled trial. Ann Emerg Med 2011; 58(6):509-16. Medline
I Neutral (Yellow) ROSC Patient PH-Paramedic Tan BKK, Chin YX, Koh ZX, Md SN, Rahmat M, Fook-Chong S, et al. Clinical evaluation of intravenous alone versus intravenous or intraosseous access for treatment of out-of-hospital cardiac arrest. Resuscitation 2021; 159:129-36. Medline
II Supportive (Green) First pass success Process ED-MD Drumheller BC, Edgar MD, Tape MK, Vongviphut D, Herres JP. Comparison of the NIO and EZIO for Resuscitative Vascular Access in the Emergency Department: A Quasi-Experimental, Before-and-After Study. Mil Med 2022. Medline
II Supportive (Green) First pass success Process ED-MD Drumheller BC, Edgar MD, Tape MK, Vongviphut D, Herres JP. Comparison of the NIO and EZIO for Resuscitative Vascular Access in the Emergency Department: A Quasi-Experimental, Before-and-After Study. Mil Med 2022. Medline
II Supportive (Green) First attempt success Patient Sunde G., Heradstveit B., Vikenes B., HeltneJ. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scan J Trauma, Resus and Emerg Med 2010; 18:52. Medline
II Supportive (Green) Success rates of establishing the access route Process PH-Paramedic Yang SC, Hsu YH, Chang YH, Chien LT, Chen IC, Chiang WC. Epinephrine administration in adults with out-of-hospital cardiac arrest: A comparison between intraosseous and intravenous route. Am J Emerg Med 2023; 67:63-9. Medline
II Neutral (Yellow) Survival to hospital discharge Patient Feinstein BA., Stubbs BA., Rea T., Kudenchuk PJ. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation 2017; 117:91-6. Medline
II Neutral (Yellow) Insertion success rate Process PH-Paramedic Frascone RJ., Jensen JP., Kaye K., Salzman JG. Consecutive field trials using two different IO devices. Prehosp Emer Care 2007; 11:164-71. Medline
II Neutral (Yellow) Neurological outcome Patient PH-Paramedic Hsieh YL, Wu MC, Wolfshohl J, d'Etienne J, Huang CH, Lu TC, et al. Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies. Scand J Trauma Resusc Emerg Med 2021; 29(1):44. Medline
II Neutral (Yellow) Neurologically favorable outcome at hospital discharge Patient Kawano T., Grunau B., Scheuermeyer FX., Gibo K., Fordyce CB., Lin S., et al. Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2018; 71(5):588-596 Medline
II Neutral (Yellow) 30-day mortality Patient PH-Paramedic Nilsson FN, Bie-Bogh S, Milling L, Hansen PM, et al. Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest. Sci Rep Nov 2023; 13(1):20796. Medline
II Neutral (Yellow) OHCA patients with IO in femur, humerus or tibia Process PH-Paramedic Rayas EG, Winckler C, Bolleter S, Stringfellow M, Miramontes D, Shumaker J, et al. Distal femur versus humeral or tibial IO, access in adult out of hospital cardiac resuscitation. Resuscitation 2022; 170:11–6. Medline
II Neutral (Yellow) First attempt IO insertion success Process PH-Paramedic Reades R., Studnek JR., Garrett JS., Vandeventer S., Blackwell T. Comparison of first-attempt success between tibial and humeral intraosseous insertions during out-of-hospital cardiac arrest. Prehosp Emerg Care 2011; 15(2):278-81. Medline
III Supportive (Green) Number of attempts required Process SIM Brenner T., Bernhard M., Helm M., Doll S., Völkl A., Ganion N., Friedmann C., Sikinger M., Knapp J., Martin E., Gries A. Comparison of two intraosseous infusion systems for adult emergency medical use. Resuscitation 2008; 78:314-9. Medline
III Supportive (Green) Success Process Kurowski A., Timler D., Evrin T., Szarpak L. Comparison of 3 different intraosseous access devices for adult during resuscitation. Randomized crossover manikin study. Am J Emerg Med 2014; 32(12):1490-3. Medline
III Supportive (Green) First attempt success Process SIM Ong ME., Ngo AS., Wijaya R. An observational, prospective study to determine the ease of vascular access in adults using a novel intraosseous access device. Ann Acad Med Singapore 2009; 38:121-4. Medline
III Supportive (Green) Time to AW insertion Process SIM Reiter DA., Strother CG., Weingart SD. The quality of cardiopulmonary resuscitation using supraglottic airways and intraosseous devices: A simulation trial. Resuscitation 2013; 84(1):93-7. Medline
III Supportive (Green) Overall placement success Process PH-Paramedic Schalk R., Schweigkofler U., Lotz G., Zacharowski K., Latasch L., Byhahn C. Efficacy of the EZ-IO needle driver for out-of-hospital intraosseous access--a preliminary, observational, multicenter study. Scand J Trauma Resusc Emerg Med 2011; 19:65-7241-19-65. Medline
III Supportive (Green) Time to insertion of IO Process Szarpak Å., Truszewski. Z, Smereka J. Which intravascular access method to choose during cardiopulmonary resuscitation? Am J Emerg Med 2016; 34(6):1160. Medline
III Supportive (Green) Success Process SIM Szarpak L, Truszewski Z, Smereka J, Krajewski P, Fudalej M, Adamczyk P, Czyzewski L. A Randomized Cadaver Study Comparing First-Attempt Success Between Tibial and Humeral Intraosseous Insertions Using NIO Device by Paramedics: A Preliminary Investigation. Medicine (Baltimore). 2016 May;95(20):e3724 Medline
X Not Yet Graded (White) - Smida T, Crowe R, Jarvis J, Ratcliff T, Goebel M. A retrospective comparison of upper and lower extremity intraosseous access during out-of-hospital cardiac arrest resuscitation. Prehosp Emerg Care February 2024; 1-23. Medline

NaHCO3
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Survival to discharge Patient PH-Paramedic & MD Alshahrani MS, Aldandan HW. Use of sodium bicarbonate in out-of-hospital cardiac arrest: a systematic review and meta-analysis. Int J Emerg Med 2021; 14(1):21. Medline
I Neutral (Yellow) Discharge from hospital Patient PH-Paramedic Dybvik T., Strand T., Steen PA. Buffer therapy during out-of-hospital cardiopulmonary resuscitation. Resuscitation 1995; 29:89-95. Medline
I Neutral (Yellow) Short-term survival Patient PH-Paramedic Xu T, Wu C, Shen Q, Xu H, Huang H. The effect of sodium bicarbonate on OHCA patients: A systematic review and meta-analysis of RCT and propensity score studies. Am J Emerg Med August 2023; 73:40-46. Medline
II Supportive (Green) Survival to hospital admission Patient ED-MD Chen YC., Hung MS., Liu CY., Hsiao CT., Yang YH. The association of emergency department administration of sodium bicarbonate after out of hospital cardiac arrest with outcomes. Am J Emerg Med 2018. Medline
II Supportive (Green) Any prehospital ROSC and survival to discharge Patient PH-Paramedic Niederberger SM, Crowe RP, Salcido DD, Menegazzi JJ. Sodium bicarbonate administration is associated with improved survival in asystolic and PEA Out-of-Hospital cardiac arrest. Resuscitation Nov 2022. Medline
II Opposes (Red) Survival Patient PH-Paramedic Kawano T., Grunau B., Scheuermeyer FX., Gibo K., Dick W., Fordyce CB, et al. Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest. Resuscitation 2017; 119:63-9. Medline
II Opposes (Red) Neurologic status at hospital discharge Patient PH-Paramedic & MD Touron M, Javaudin F, Lebastard Q, Baert V, Heidet M, Hubert H, et al. Effect of sodium bicarbonate on functional outcome in patients with out-of-hospital cardiac arrest: a post-hoc analysis of a French and North-American dataset. Eur J Emerg Med 2022. Medline
III Neutral (Yellow) ROSC Process PH-Paramedic Bar-Joseph G., Abramson NS., Kelsey SF., Mashiach T., Craig MT., Safar P., et al. Improved resuscitation outcome in emergency medical systems with increased usage of sodium bicarbonate during cardiopulmonary resuscitation. Acta Anaesthesiol Scand 2005; 49(1):6-15. Medline
III Neutral (Yellow) Prevalence of SB-induced alkalemia Process ED-MD Geraci M., Dusko K., Heckman MG., Persoff J. Prevalence of Sodium Bicarbonate-Induced Alkalemia in Cardiopulmonary Arrest Patients. Ann Pharm 2009; 43:1245-50. Medline
III Neutral (Yellow) Survival time Patient PH-Paramedic Wang HE., Min A., Hostler D., Chang CC., Callaway CW. Differential effects of out-of-hospital interventions on short- and long-term survival after cardiopulmonary arrest. Resuscitation 2005; 67(1):69-74. Medline

NaHCO3 in special cases
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Feasibility Patient PH-Paramedic McArthur R, Rafique Z, Ward B, Rodriguez L, Dickson R, Patrick C. Treatment of Presumed Hyperkalemia in the Prehospital Setting. Prehosp Disaster Med 2022; 1–5. Medline

NaHCO3-after long arrest
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Functional Improves Outcome in Prolonged Prehospital Cardiac Arrest Patient PH-Paramedic Vukmir R., Katz L., Sodium Bicarbonate Study Group. Sodium Bicarbonate Improves Outcome in Prolonged Prehospital Cardiac Arrest. Ann JEM 2006; 24:156-161. Medline
III Supportive (Green) Successful resuscitation without deficit Patient PH-Paramedic Schmidt U., Fritz KW., Kasperczyk W., Tscherne H. Successful resuscitation of a child with severe hypothermia after cardiac arrest of 88 minutes. Prehosp Disaster Med 1995; 10(1):60-2. Medline
III Neutral (Yellow) ROSC Process PH-Paramedic Bar-Joseph G., Abramson NS., Kelsey SF., Mashiach T., Craig MT., Safar P., et al. Improved resuscitation outcome in emergency medical systems with increased usage of sodium bicarbonate during cardiopulmonary resuscitation. Acta Anaesthesiol Scand 2005; 49(1):6-15. Medline
III Neutral (Yellow) Prevalence of SB-induced alkalemia Process ED-MD Geraci M. Prevalence of Sodium Bicarbonate-induced Alkalemia in Cardiopulmonary Arrest patients. Ann Pharm 2009; 43(7):1245-50. Medline

Norepinephrine
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Incidence of re-arrest Patient ED-MD Sharpe AR, Richardson K, Stanton M, et al. Lack of Association of Initial Vasopressor Dosing with Survival and Cardiac Re-Arrest Likelihood After Return of Spontaneous Circulation. J Emerg Med Sept 2023; 65(3):e209-20. Medline

Normal saline
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) pH indicators at 24 hours Patient ED-MD Woo JH, Lim YS, Cho JS, Yang HJ, Jang JH, Choi JY, Choi WS. Saline versus Plasma Solution-A in Initial Resuscitation of Patients with Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. J Clin Med July 2023; 12(15). Medline

Opiate overdose descision tool
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Appropriate recognition for use Patient PH-Paramedic Sumner SA., Mercado-Crespo MC., Spelke MB., Paulozzi L., Sugerman DE., Hillis SD., et al. Use of Naloxone by Emergency Medical Services during Opioid Drug Overdose Resuscitation Efforts. Prehosp Emerg Care 2016; 20(2):220-225. Medline
III Supportive (Green) Cause of Death Patient PH-Paramedic Rodriguez RM, Tseng ZH, Montoy JCC, Repplinger D, Moffatt E, Addo N, et al. NAloxone CARdiac Arrest Decision Instruments (NACARDI) for targeted antidotal therapy in occult opioid overdose precipitated cardiac arrest. Resuscitation 2021; 159:69-76. Medline

Oxygen-titrated
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) No change in 3x3 table Patient PH-Paramedic Izawa J, Komukai S, Nishioka N, Kiguchi T, Kitamura T, Iwami T. Outcomes associated with intra-arrest hyperoxaemia in out-of-hospital cardiac arrest: A registry-based cohort study. Resuscitation Nov 2022; 181:173–81. Medline

PAI-CPR/Defib
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) CPR quality Process Lin YY., Chiang WC., Hsieh MJ., Sun JT., Chang YC., Ma MH. Quality of audio-assisted versus video-assisted dispatcher-instructed bystander cardiopulmonary resuscitation: A systematic review and meta-analysis. Resuscitation 2018; 123:77-85. Medline
I Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Hallstrom AP. Dispatcher-assisted "phone" cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. Crit Care Med 2000; 28(S11):N190-2. Medline
I Neutral (Yellow) Survival Patient PH-Paramedic Hupfl M., Selig HF., Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: A meta-analysis. Lancet 2010; 376(9752):1552-7. Medline
I Neutral (Yellow) 30 Day Survival Patient PH-Paramedic Svensson L., et al. Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest. NEJM 2010; 363:434-442. Medline
II Supportive (Green) survival to hospital discharge Patient PH-Paramedic Chang I, Ro YS, Shin SD, Song KJ, Park JH, Kong SY. Association of dispatcher-assisted bystander cardiopulmonary resuscitation with survival outcomes after pediatric out-of-hospital cardiac arrest by community property value. Resuscitation 2018; 132:120-6. Medline
II Supportive (Green) Survival to discharge (neuro intact). Patient PH-Bystander Eberhard KE, Linderoth G, Gregors MCT, Lippert F, Folke F. Impact of dispatcher-assisted cardiopulmonary resuscitation on neurologically intact survival in out-of-hospital cardiac arrest: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29(1):70. Medline
II Supportive (Green) Survival from OHCA Patient PH-Bystander Gantzel Nielsen C, Andelius LC, Hansen CM, Blomberg SNF, Christensen HC, Kjølbye JS, et al. Bystander interventions and survival following out-of-hospital cardiac arrest at Copenhagen International Airport. Resuscitation 2021. Medline
II Supportive (Green) Initial shockable rhythm Patient PH-Bystander Goto Y, Funada A, Maeda T. Association of dispatcher-assisted cardiopulmonary resuscitation with initial shockable rhythm and survival after out-of-hospital cardiac arrest. Eur J Emerg Med 2021. Medline
II Supportive (Green) 1-month neurologically intact survival Process PH-Paramedic Goto Y, Funada A, Maeda T. Dispatcher instructions for bystander cardiopulmonary resuscitation and neurologically intact survival after bystander-witnessed out-of-hospital cardiac arrests: a nationwide, population-based observational study. Crit Care 2021; 25(1):408. Medline
II Supportive (Green) Survival to hospital discharge with good neurological outcome. Patient PH-Bystander Grubic N, Peng YP, Walker M, Brooks SC; CARES Surveillance Group. Bystander-initiated cardiopulmonary resuscitation and automated external defibrillator use after out-of-hospital cardiac arrest: Uncovering disparities in care and survival across the urban-rural spectrum. Resuscitation 2022; 175:150–8. Medline
II Supportive (Green) Likelihood of survival Process PH-Bystander Guerrero A, Blewer AL, Joiner AP, Leong BSH, Shahidah N, Pek PP, et al. Evaluation of Telephone-Assisted Cardiopulmonary Resuscitation Recommendations for Out-Of-Hospital Cardiac Arrest. Resuscitation 2022. Medline
II Supportive (Green) Bystander defibrillation according to the location of the cardiac arrest Process Hansen SM., Hansen CM., Folke F., Rajan S., Kragholm K., Ejlskov L., et al. Bystander Defibrillation for Out-of-Hospital Cardiac Arrest in Public vs Residential Locations. JAMA cardiology 2017; 2(5):507-14. Medline
II Supportive (Green) Survival to admission Patient Harjanto S., Na MX., Hao Y., Ng YY., Doctor N., Goh ES., et al. A before-after interventional trial of dispatcher-assisted cardio-pulmonary resuscitation for out-of-hospital cardiac arrests in Singapore. Resuscitation 2016; 102:85-93. Medline
II Supportive (Green) Survival at hospital discharge with a good neurological outcome Patient ED-Paramedic & MD Hong Tuan Ha V, Jost D, Bougouin W, Joly G, et al. Trends in survival from out-of-hospital cardiac arrest with a shockable rhythm and its association with bystander resuscitation: a retrospective study. Emerg Med J August 2023. Medline
II Supportive (Green) Neurologic outcome Patient PH-Bystander HS L, You K, JP J, Kim C, Kim S. The effect of video-instructed versus audio-instructed dispatcher-assisted cardiopulmonary resuscitation on patient outcomes following out of hospital cardiac arrest in Seoul. Sci Rep 2021; 11(1):15555. Medline
II Supportive (Green) Neurologic recovery at hospital discharge Patient PH-Bystander Kim MW, Kim TH, Song KJ, Shin SD, Kim CH, Lee EJ, et al. Comparison between dispatcher-assisted bystander CPR and self-led bystander CPR in out-of-hospital cardiac arrest (OHCA). Resuscitation 2021; 158:64-70. Medline
II Supportive (Green) Survival at 1 month with a favorable neurologic outcome Patient Kitamura T., Kiyohara K., Sakai T., Matsuyama T., Hatakeyama T., Shimamoto T., et al. Public-Access Defibrillation and Out-of-Hospital Cardiac Arrest in Japan. N Engl J Med 2016; 375(17):1649-59. Medline
II Supportive (Green) One-month survival with favorable neurological outcome Patient Kiyohara K., Kitamura T., Sakai T., Nishiyama C., Nishiuchi T., Hayashi Y., et al. Public-access AED pad application and outcomes for out-of-hospital cardiac arrests in Osaka, Japan. Resuscitation 2016; 106:70-5. Medline
II Supportive (Green) Accurate identification Process PH-Bystander Ng JYX, Sim ZJ, Siddiqui FJ, Shahidah N, Leong BS, et al. Incidence, characteristics and complications of dispatcher-assisted cardiopulmonary resuscitation initiated in patients not in cardiac arrest. Resuscitation 2022; 170:266–73. Medline
II Supportive (Green) Survival to discharge Process PH-Bystander Ong MEH, Shin SD, Ko PC, Lin X, Ma MH, Ryoo HW, Wong KD, et al. International multi-center real world implementation trial to increase out-of-hospital cardiac arrest survival with a dispatcher-assisted cardio-pulmonary resuscitation package (Pan-Asian resuscitation outcomes study phase 2). Resuscitation 2022; 171:80–9. Medline
II Supportive (Green) Good neurologic recovery at discharge. Patient Park JH., Ro YS., Shin SD., Song KJ., Hong KJ., Kong SY. Dispatcher-assisted bystander cardiopulmonary resuscitation in rural and urban areas and survival outcomes after out-of-hospital cardiac arrest. Resuscitation 2018; 125:1-7. Medline
II Supportive (Green) 30-day survival Process Other Riva G, Jonsson M, Ringh M, Claesson A, Djärv T, Forsberg S, et al. Survival after dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest. Resuscitation 2020; 157:195-201. Medline
II Supportive (Green) Survival to discharge Patient Ro YS., Shin SD., Lee YJ., Lee SC., Song KJ., Ryoo HW., et al. Effect of Dispatcher-Assisted Cardiopulmonary Resuscitation Program and Location of Out-of-Hospital Cardiac Arrest on Survival and Neurologic Outcome. Ann Emerg Med 2017; 69(1):52-61.e1. Medline
II Supportive (Green) ROSC Patient PH-Bystander Siman-Tov M, Strugo R, Podolsky T, Rosenblat I, Blushtein O. Impact of dispatcher assisted CPR on ROSC rates: A National Cohort Study. Am J Emerg Med 2021; 44:333–8. Medline
II Supportive (Green) Shockable rhythm on first EKG Process Takahashi H., Sagisaka R., Natsume Y., Tanaka S., Takyu H., Tanaka H. Does dispatcher-assisted CPR generate the same outcomes as spontaneously delivered bystander CPR in Japan? Am J Emerg Med 2018; 36(3):384-91. Medline
II Supportive (Green) Rate of Bystander CPR (B-CPR) Process PH-Bystander Wong XY, Fan Q, Shahidah N, De Souza CR, Arulanandam S, Ng YY, et al. Impact of dispatcher-assisted cardiopulmonary resuscitation and myResponder mobile app on bystander resuscitation. Ann Acad Med Singap 2021; 50(3):212-21 Medline
II Supportive (Green) Survival to discharge Patient Wu Z., Panczyk M., Spaite DW., Hu C., Fukushima H., Langlais B., et al. Telephone cardiopulmonary resuscitation is independently associated with improved survival and improved functional outcome after out-of-hospital cardiac arrest. Resuscitation 2018; 122:135-40. Medline
II Supportive (Green) Neurologically favourable outcome 1 month after cardiac arrest Patient PH-Bystander Yoshimoto H, Fukui K, Nishimoto Y, et al. Annual improvement trends in resuscitation outcome of patients defibrillated by laypersons after out-of-hospital cardiac arrests and compression-only resuscitation of laypersons. Resuscitation 2023; 183:109672. Medline
II Neutral (Yellow) Consistency Process SIM Ballesteros-Peña S, Fernández-Aedo I, Vallejo-De la Hoz G, Etayo-Sancho A, Alonso-Pinillos A. Analysis of dispatcher-assisted cardiopulmonary resuscitation instructions to laypersons in an out-of-hospital cardiac arrest. Anales del Sistema Sanitario de Navarra 2020; 43(2):203-7. Medline
II Neutral (Yellow) Survival to Discharge Patient PH-Paramedic Bohm K., Vaillancourt C., Charette ML., Dunford J., Castren M. In patients with out-of-hospital cardiac arrest, does the provision of dispatch cardiopulmonary resuscitation instructions as opposed to no instructions improve outcome: A systematic review of the literature. Resuscitation 2011; 82(12):1490-5. Medline
II Neutral (Yellow) Frequency of bystander CPR Process PH-Paramedic Fujie K., Nakata Y., Yasuda S., Mizutani T., Hashimoto K. Do dispatcher instructions facilitate bystander-initiated cardiopulmonary resuscitation and improve outcomes in patients with out-of-hospital cardiac arrest? A comparison of family and non-family bystanders. Resuscitation 2014; 85(3):315-9. Medline
II Neutral (Yellow) Bystander CPR performance/ quality Process Fukushima H., Kawai Y., Asai H., Seki T., Norimoto K., Urisono Y., et al. Performance review of regional emergency medical service pre-arrival cardiopulmonary resuscitation with or without dispatcher instruction: a population-based observational study. Acute medicine & surgery 2017; 4(3):293-9. Medline
II Neutral (Yellow) Initial shockable rhythm Patient PH-Paramedic Goto Y, Funada A, Maeda T. Association of dispatcher-assisted cardiopulmonary resuscitation with initial shockable rhythm and survival after out-of-hospital cardiac arrest. Eur J Emerg Med 2022; 29(1):42–8. Medline
II Neutral (Yellow) Favourable neurological outcome Patient PH-Paramedic Japanese Circulation Society Resuscitation Science Study Group. Chest-compression-only bystander cardiopulmonary resuscitation in the 30:2 compression-to-ventilation ratio era. nationwide observational study. Circ J 2013; 77(11):2742-50. Medline
II Neutral (Yellow) Favourable neurological outcome at 1 mo. Patient PH-Bystander Komori A, Iriyama H, Abe T. Impact of defibrillation with automated external defibrillator by bystander before defibrillation by emergency medical system personnel on neurological outcome of out-of-hospital cardiac arrest with non-cardiac etiology. Resusc Plus 2023; 13:100363. Medline
II Neutral (Yellow) Survival to ED Patient Lwanga A., Garcia-Sayan E., Lwanga S., Karreman E., Mohamed A. Automated External Defibrillators and Survival After Nonresidential Out of Hospital Cardiac Arrest in a Small North American City. Am J Cardiol 2017; 119(12):1979-82. Medline
II Neutral (Yellow) Survival to hospital discharge Patient Shah M., Bartram C., Irwin K., Vellano K., McNally B., Gallagher T., et al. Evaluating Dispatch-Assisted CPR Using the CARES Registry. Prehosp Emerg Care 2018; 22(2):222-228. Medline
II Neutral (Yellow) Recognition Process PH-Paramedic Vaillancourt C., Verma A., Trickett J., et al. Evaluating the effectiveness of dispatch-assisted cardiopulmonary resuscitation instructions. Acad Emerg Med 2007; 14(10):877-883. Medline
III Supportive (Green) CPR Compression Rate and Depth Process SIM Birkenes TS., Myklebust H., Neset A., Kramer-Johansen J. Quality of CPR performed by trained bystanders with optimized pre-arrival instructions. Resuscitation 2014; 85(1):124-30. Medline
III Supportive (Green) Chest compression rate and depth Process SIM Dias JA., Brown TB., Saini D., et al. Simplified dispatch-assisted CPR instructions outperform standard protocol. Resuscitation 2007; 72(1):108-14. Medline
III Supportive (Green) Successful shock delivery Process SIM Ecker R., Rea TD., Meischke H., Schaeffer SM., Kudenchuk P., Eisenberg MS. Dispatcher assistance and automated external defibrillator performance among elders. Acad Emerg Med 2001; 8(10):968-73. Medline
III Supportive (Green) Chest Compression Quality Process SIM Lee SGW, Kim TH, Lee HS, Shin SD, Song KJ, Hong KJ, et al. Efficacy of a new dispatcher-assisted cardiopulmonary resuscitation protocol with audio call-to-video call transition. Am J Emerg Med 2021; 44:26-32. Medline
III Supportive (Green) Safety Process PH-Paramedic Lerner EB., Sayre MR., Brice JH., et al. Cardiac arrest patients rarely receive chest compressions before ambulance arrival despite the availability of pre-arrival CPR instructions. Resuscitation 2008; 77(1):51-56. Medline
III Supportive (Green) Composite outcome score based on time to first compression, hand position, chest compression depth and rate and hands-off time Patient Rasmussen SE., Nebsbjerg MA., Krogh LQ., Bjørnshave K., Krogh K., Povlsen JA., et al. A novel protocol for dispatcher assisted CPR improves CPR quality and motivation among rescuers-A randomized controlled simulation study. Resuscitation 2017; 110:74-80. Medline
III Supportive (Green) CPR quality - no flow time Process Spelten O., Warnecke T., Wetsch WA., Schier R., Böttiger BW., Hinkelbein J. Dispatcher-assisted compression-only cardiopulmonary resuscitation provides best quality cardiopulmonary resuscitation by laypersons: A randomised controlled single-blinded manikin trial. Eur J Anaesthesiol 2016; 33(8):575-80. Medline
III Supportive (Green) Accuracy Patient PH-Paramedic Vaillancourt C., Charette M., Kasaboski A., et al. Cardiac arrest diagnostic accuracy of 9-1-1 dispatchers: A prospective multi-center study. Resuscitation 2015; 90:116-120. Medline
III Supportive (Green) Time to First Compression Process PH-Paramedic Van Vleet LM., Hubble MW. Time to first compression using medical priority dispatch system compression-first dispatcher-assisted cardiopulmonary resuscitation protocols. Prehosp Emerg Care 2012; 16(2):242-250. Medline
III Supportive (Green) Time to first compression Process SIM Williams JG., Brice JH., De Maio VJ., Jalbuena T. A simulation trial of traditional dispatcher-assisted CPR versus compressions--only dispatcher-assisted CPR. Prehosp Emerg Care 2006; 10(2):247-253. Medline
III Neutral (Yellow) Rate of Administration of PAI-CPR Process PH-Paramedic Bohm K. Dispatcher-assisted telephone guided CPR: An underused lifesaving system. Eur J Emerg Med 2007; 4:256-9. Medline
III Neutral (Yellow) Quality of CPR Process PH-Paramedic Brown TB., Saini D., Pepper T., Mirza M., et al. Instructions to « put the phone down » do not improve the quality of bystander initiated, dispatcher-assisted cardiopulmonary resuscitation. Resusc 2008; 76(2)249-55. Medline
III Neutral (Yellow) Diagnostic accuracy of advanced medical priority dispatch system (AMPDS) software Process PH-Paramedic Cairns KJ., Hamilton AJ., Marshall AH., Moore MJ., Adgey AA., Kee F. The obstacles to maximising the impact of public access defibrillation: An assessment of the dispatch mechanism for out-of-hospital cardiac arrest. Heart 2008; 94(3):349-53. Medline
III Neutral (Yellow) CPR quality Process SIM Dorph E., Wik L., Steen PA. Dispatcher-assisted cardiopulmonary resuscitation. An evaluation of efficacy amongst elderly. Resuscitation 2003; 56(3):265-73. Medline
III Neutral (Yellow) Time to first compression Patient SIM Harve H., Jokela J., Tissari A., et al. Can untrained laypersons use a defibrillator with dispatcher assistance? Acad Emerg Med 2007; 14(7):624-8. Medline
III Neutral (Yellow) Ventilation quality Patient SIM Harve H., Jokela J., Tissari A., et al. Defibrillation and the quality of layperson cardiopulmonary resuscitation-dispatcher assistance or training? Resuscitation 2009; 80(2):275-7. Medline
III Neutral (Yellow) Efficacy Process SIM Lee JS., Jeon WC., Ahn JH., Cho YJ., Jung YS., Kim GW. The effect of a cellular-phone video demonstration to improve the quality of dispatcher-assisted chest compression-only cardiopulmonary resuscitation as compared with audio coaching. Resuscitation 2011; 82(1):64-8. Medline
III Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Rea TD., Fahrenbruch C., Culley L., Donohoe RT., Hambly C., Innes J., et al. CPR with chest compression alone or with rescue breathing. N Engl J Med 2010; 363(5):423-33. Medline
III Neutral (Yellow) Relative compression depth Process SIM van Tulder R., Roth D., Krammel M., et al. Effects of repetitive or intensified instructions in telephone assisted, bystander cardiopulmonary resuscitation: An investigator-blinded, 4-armed, randomized, factorial simulation trial. Resuscitation 2014; 85(1):112-118. Medline
III Neutral (Yellow) CPR metrics Process SIM Woollard M., Smith A., Whitfield R., et al. To blow or not to blow: A randomised controlled trial of compression-only and standard telephone CPR instructions in simulated cardiac arrest. Resuscitation 2003; 59(1):123-131. Medline
III Opposes (Red) Time to initiating CPR Process SIM Angkoontassaneeyarat C, Yuksen C, Jenpanitpong C, Rukthai P, Seanpan M, Pongprajak D, et al. Effectiveness of a Dispatcher-Assisted Cardiopulmonary Resuscitation Program Developed by the Thailand National Institute of Emergency Medicine (NIEMS). Prehosp Disaster Med 2021; 36(6):702–7. Medline
X Not Yet Graded (White) - Miyako J, Nakagawa K, Sagisaka R, et al. Association between bystander intervention and emergency medical services and the return of spontaneous circulation in out-of-hospital cardiac arrests occurring at a train station in the Tokyo metropolitan area: A retrospective cohort study. Resusc Plus August 2023; 15:100438. Medline
X Not Yet Graded (White) - Simmons KM, McIsaac SM, Ohle R. Impact of community-based interventions on out-of-hospital cardiac arrest outcomes: a systematic review and meta-analysis. Sci Rep 2023; 13(1):10231. Medline

Passive leg raise
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) neurological outcome Patient PH-Paramedic & MD Azeli Y, Bardají A, Barbería E, Lopez-Madrid V, Bladé-Creixenti J, Fernández-Sender L, Bonet G, Rica E, Álvarez S, Fernández A, Axelsson C, Jiménez-Herrera MF. Clinical outcomes and safety of passive leg raising in out-of-hospital cardiac arrest: a randomized controlled trial. Crit Care 2021; 25(1):176. Medline

Passive Oxygen Administration
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) ABG Patient PH-Paramedic Saissy JM., et al. Efficacy of continuous insufflation of oxygen combined with active cardiac compression-decompression during OOHCA. Anesthesiology 2000; 92:1523-30. Medline
I Neutral (Yellow) ROSC, Survival to Admission Process PH-Paramedic Bertrand C., et al. Constant flow insufflation of oxygen as the sole mode of ventilation during OOHCA. Intensive Care Med 2006; 32:843-51. Medline
II Supportive (Green) Neurologically intact survival to hospital discharge Patient PH-Paramedic Bobrow BJ., Ewy GA., Clark L., et al. Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med 2009; 54(5):656-62. Medline

Pit-crew CPR
Level Direction Primary Outcome Patient/Process Setting Reference

POCUS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Focused cardiac ultrasound Process ED-MD Balderson JR, You AX; Evans DP, Taylor LA, Gertz ZM. Feasibility of focused cardiac ultrasound during cardiac arrest in the emergency department. Cardiovasc Ultrasound 2021; 19(1):19. Medline
II Supportive (Green) Predicting survival to hospital admission Process Gaspari R., Weekes A., Adhikari S., Noble VE., Nomura JT., Theodoro D., et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation 2017; 109:33-9. Medline
II Supportive (Green) Hands off time Process PH-MD & CCT Hafner C, Manschein V, Klaus DA, et al. Live stream of prehospital point-of-care ultrasound during cardiopulmonary resuscitation - A feasibility trial. Resuscitation 2023; 194:110089. Medline
III Supportive (Green) US to detect ROSC Process PH-Paramedic Humphries AL, White JMB, Guinn RE, Braude DA. Paramedic-Performed Carotid Artery Ultrasound Heralds Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Case Report. Prehosp Emerg Care 2022:1–5. Medline
III Supportive (Green) Novel application of ultrasound Patient PH-Paramedic Humphries AL, White JMB, Guinn RE, Braude DA. Paramedic-Performed Carotid Artery Ultrasound Heralds Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Case Report. Prehosp Emerg Care 2022:1–5. Medline
III Supportive (Green) Adequacy and accuracy Process PH-Paramedic Kreiser MA, Hill B, Karki D, Wood E, Shelton R, Peterson J, et al. Point-of-Care Ultrasound Use by EMS Providers in Out-of-Hospital Cardiac Arrest. Prehosp Disaster Med 2022; 37(1):39–44 Medline
III Supportive (Green) Detection of underlying cause of PEA Process PH-Paramedic Van den Bempt S, Wauters L, Dewolf P. Pulseless Electrical Activity: Detection of Underlying Causes in a Prehospital Setting. Med Princ Pract. 2021;30(3):212-222. doi: 10.1159/000513431. Epub 2020 Nov 30. PMID: 33254164; PMCID: PMC8280430. Medline
III Supportive (Green) Identification of important conditions Process Zengin S., Yavuz E., Cindoruk A., Altunba G., et al. Benefits of cardiac sonography performed by a non-expert sonographer in patients with non-traumatic cardiopulmonary arrest. Resuscitation 2016; 102:105-9. Medline
III Neutral (Yellow) Survival Patient PH-Paramedic & MD Soták M, Tyll T, Pochop M. The Role of Ultrasound Examination in The Differential Diagnosis Of Cardiac Arrest In Prehospital Care: A Case Report. Prehosp Emerg Care 2022; 1–4. Medline
X Not Yet Graded (White) - Albaroudi O, Albaroudi B, Haddad M, et al. Can absence of cardiac activity on point-of-care echocardiography predict death in out-of-hospital cardiac arrest? A systematic review and meta-analysis. Ultrasound J February 2024; 16(1):10. Medline
X Not Yet Graded (White) - Zaki HA, Iftikhar H, Shaban EE, et al. The role of point-of-care ultrasound (POCUS) imaging in clinical outcomes during cardiac arrest: a systematic review. Ultrasound J January 2024; 16(1):4. Medline

Precordial Thump
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) Rhythm conversion, mortality Process In-Patient Caldwell G., Millar G., Quinn E., Vincent R., Chamberlain DA. Simple Mechanical Methods for Cardioversion: Defense of the Precordial Thump and Cough Version. BMJ 1985; 291:627-30. Medline
III Opposes (Red) Sternum fracture Patient PH-Paramedic Ahmar W., Morely P., Marasco S., Chan W., Aggarwal A. Sternal fracture and Osteomyelitis: An Unusual Complication of a Precordial Thump. Resus 2007; 75:540-2. Medline
III Opposes (Red) Effectiveness of precordial thump Patient Other Dee R, Smith M, Rajendran K, Perkins GD, Smith CM, Vaillancourt C, et al. The effect of alternative methods of cardiopulmonary resuscitation - Cough CPR, percussion pacing or precordial thump - on outcomes following cardiac arrest. A systematic review. Resuscitation 2021; 162:73-81. Medline