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2020 AHA Guidelines for CPR and ECC: Adult Basic & Advanced Life Support

2020 Guidelines Highlights coverEvery 5 years, the American Heart Association (AHA) revises the recommendations, or Guidelines, for Emergency Cardiovascular Care (ECC), including CPR. Here is a summary of some of the key issues and major changes for Adult Basic and Advanced Life Support. These were released on October 21, 2020, and will be implemented into AHA classes over the next few months.

Summary of Key Issues and Major Changes 

- In 2015, 350,000 US adults experienced nontraumatic OHCA attended by EMS. 

- Less than 40% of adults receive layperson-initiated CPR.

- Fewer than 12% have an AED applied before EMS arrival.

- Survival from OHCA has plateaued since 2012.

- 1.2% of adults admitted to US hospitals suffer IHCA.

Major new changes include:

- Enhanced algorithms and visual aids.

- Early initiation of CPR by lay rescuers re-emphasized. 

- Emphasis on early epinephrine administration.

- Real-time audiovisual feedback is recommended.

- IBP and ETCO2 monitoring during resuscitation may improve CPR quality. 

- Routine use of double sequential defibrillation is not recommended. 

- IV access preferred route of medication administration during ACLS resuscitation.

- Intraosseous (IO)  access is acceptable if IV access is not available.  

- Care after ROSC requires attention to oxygenation, BP control, evaluation for PCI, TTM, and multimodal neuroprognostication. 

- Patients should have formal assessment and support for their physical, cognitive, and psychosocial needs. 

- After resuscitation, debriefing for lay rescuers, EMS providers, and hospital-based healthcare workers may be beneficial to support their mental health and well-being. 

- Management of cardiac arrest in pregnancy focuses on maternal resuscitation, with preparation for early perimortem cesarean delivery if necessary to save the infant and improve the chances of successful resuscitation of  the mother. 

Algorithms and Visual Aids 

- A sixth link, Recovery, was added to the Chains of Survival.

- Adult Cardiac Arrest Algorithm emphasizes early epinephrine for nonshockable rhythms.

- Two new Opioid-Associated Emergency Algorithms added.

- The Post–Cardiac Arrest Care Algorithm was updated to emphasize the need to prevent hyperoxia, hypoxemia, and hypotension

- A new diagram has been added to guide and inform neuroprognostication.

- A new Cardiac Arrest in Pregnancy Algorithm added to address special cases.

AHA Chains of Survival for adult IHCA and OHCA


 AHA Adult Basic Life Support Algorithm for Healthcare Providers


AHA Adult Cardiac Arrest Algorithm


 AHA Adult Cardiac Arrest Circular Algorithm



AHA Adult Post–Cardiac Arrest Care Algorithm



Multimodal neuroprognostication in adult patients after cardiac arrest



Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm



AHA Advanced Airway Placement



AHA Opioid-Associated Emergency for Lay Responders Algorithm



AHA Opioid-Associated Emergency for Healthcare Providers Algorithm



Major New and Updated Recommendations  


Early Initiation of CPR by Lay Rescuers 

- Laypersons should initiate CPR for presumed cardiac arrest; the risk of harm to the patient is low if the patient is not in cardiac arrest.  

Early Administration of Epinephrine 

- With respect to timing, for cardiac arrest with a nonshockable rhythm, it is  reasonable to administer epinephrine as soon as feasible. 

- With respect to timing, for cardiac arrest with  a shockable rhythm, it may be reasonable to administer epinephrine after initial defibrillation attempts have failed. 

- 2 randomized trials of epinephrine enrolling more than 8500 patients with OHCA, showing that epinephrine increased ROSC and survival. 

Real-Time Audiovisual Feedback 

- It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance. 

- 25% increase in survival to hospital discharge from IHCA with audio feedback on compression depth and recoil.  

Physiologic Monitoring of CPR Quality 

- It may be reasonable to use physiologic parameters such as arterial blood pressure or ETCO2 when feasible to monitor and optimize CPR quality. 

- Higher likelihood of ROSC when CPR quality is monitored using either ETCO2 or diastolic blood pressure.  

- Targeting compressions to an ETCO2>10 mm Hg, ideally>20 mm Hg, may be useful as a marker of CPR quality. An ideal target has not been identified. 

Double Sequential Defibrillation Not Supported 

- The usefulness of double sequential defibrillation for refractory shockable rhythm has not been established. 

- Double sequential defibrillation is the practice of applying near simultaneous shocks using 2 defibrillators. 

- Some case reports have shown good outcomes.

- No evidence to support double sequential defibrillation; recommend against its routine use. 

IV Access Preferred Over IO 

- First attempt IV access for drug administration in cardiac arrest. 

- The IV route associated with better clinical outcomes in 5 retrospective studies. 

- For situations in which IV access is difficult, IO access is a reasonable option.  

Post–Cardiac Arrest Care and Neuroprognostication 

- Treatment of hypotension, titrating oxygen to avoid both hypoxia and hyperoxia, detection and treatment of seizures, and TTM reaffirmed with new evidence.  

- Neuroprognostication performed no sooner than 72 hours after return to normothermia, and prognostic decisions should be based on multiple modes of patient assessment.  

Care and Support During Recovery 

- Cardiac arrest survivors should have multimodal rehabilitation assessment and treatment for physical, neurologic, cardiopulmonary,  and cognitive impairments before  discharge from the hospital. 

- Cardiac arrest survivors and their caregivers should receive comprehensive, multidisciplinary discharge planning, to include medical and rehabilitative treatment  recommendations and return to activity/work expectations. 

- Structured assessment for anxiety, depression, post traumatic stress, and fatigue for  cardiac arrest survivors and their caregivers. 

- Recovering from cardiac arrest extends long after the initial hospitalization. 

- Support is needed during recovery to ensure optimal physical, cognitive, and emotional well-being and return to social/role functioning. This process should be initiated during the initial hospitalization and continue as long as needed.

Debriefings for Rescuers 

- Debriefings and referral for follow up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after cardiac arrest is beneficial.

- Rescuers may experience anxiety or posttraumatic stress about providing or not providing BLS or experience emotional or psychological effects of caring for a patient with cardiac arrest. 

- Team debriefings may allow a review of team performance (education, quality improvement) as well as recognition of the natural stressors associated with caring for a patient near death.

Cardiac Arrest in Pregnancy 

- Pregnant patients prone to hypoxia so oxygenation and airway management prioritized during resuscitation from cardiac arrest in pregnancy. 

- Fetal monitoring should not be undertaken during cardiac arrest in pregnancy. 

- TTM for pregnant women who remain comatose after cardiac arrest resuscitation.

- The Fetus should be continuously monitored for bradycardia during TTM.

- Obstetric and neonatal consultation should be sought. 

For more information about the 2020 AHA Guidelines, please review our other blogs or visit

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