Previous changes

September 2023 — reviewed. A literature search was conducted in August 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. There have been minor structural changes to the topic, with the addition of two scenarios, 'Out of hospital post-resuscitation care' and 'Terminating resuscitation'. Vasopressor and antiarrhythmic paediatric dose recommendations have been added to the 'Basis for Recommendation' for the management of shockable and non-shockable rhythm sections. Minor changes to the recommendations have been updated in line with current guidance, including an update to the recommended lidocaine dose (from 1 mg/kg to 100 mg).

July 2018 — reviewed. A literature search was conducted in July  2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. 

October 2013 — reviewed. A literature search was conducted in September 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Changes have been made in line with those made by the Resuscitation Council in their updated Resuscitation Guidelines issued in 2010. Greater importance is placed on good quality chest compressions and reducing the number and duration of pauses when giving chest compressions. Recommendations to use atropine have been removed and a correction made about when to give amiodarone and adrenaline to people with a shockable rhythm.

January 2011 — minor update to the text to reflect new guidance issued by the Resuscitation Council (UK). 

February 2010 — minor update to the text regarding the use of laryngeal face masks used to secure the airway. 

October 2008 to February 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 August 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2023.

Systematic reviews and meta-analyses

No new systematic reviews published since August 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since August 2023.

New policies

No new national policies or guidelines since 1 August 2023.

New safety alerts

No new safety alerts since 1 August 2023.

Changes in product availability

No changes in product availability since 1 August 2023.

How should I assess someone with a suspected cardiac arrest?

• Suspect cardiac arrest if the person is unresponsive and not breathing normally.
  • Slow or laboured breathing (agonal breathing) by an unconscious person should be considered a sign of cardiac arrest.
• Ensure that it is safe to approach the person.
• Check the person for a response — gently shake their shoulders and ask loudly, 'Are you all right?'
  • If the person responds, leave them in the position in which you find them, try to find out what is wrong and get help if required.
• If there is no response: 
  • Open the airway:
    • Turn the person onto their back.
    • Place your hand on their forehead and gently tilt the head back.
    • With your fingertips under their chin, lift it to open the airway.
    • Ensure the airway is not obstructed by a foreign body.
  • Look, listen and feel for normal breathing for no more than 10 seconds. 
    • Agonal gasps (infrequent, irregular breaths) are common in the first few minutes after a sudden cardiac arrest — they should not be considered to be normal breathing.
    • If in any doubt, act as if they are not breathing normally, and prepare to start cardiopulmonary resuscitation (CPR).  
  • Shout for help if there is still no response and the person is not breathing normally:
    • If possible, ask someone to call 999 to dispatch an ambulance, or do it yourself if necessary.
    • Stay with the person and activate the phone's speaker function to make communication with the ambulance service easier.
  • Send someone to get an automated external defibrillator (AED) if available.
    • If you are alone, do not leave the person, start CPR.
    • Ambulance services may have up-to-date information on the location of community AEDs.
• An algorithm for adult basic life support is available on the Resuscitation Council (UK) website (www.resus.org.uk).
• If a person is unresponsive but breathing normally:
  • Place the person in the recovery position.
  • Be prepared to start or restart CPR should the person stop breathing or their breathing becomes abnormal.

How do I perform cardiopulmonary resuscitation?

• If an automated external defibrillator (AED) is available, use it as soon as possible. Perform cardiopulmonary resuscitation (CPR) until an AED becomes available.
• Start chest compressions:
  • Kneel by the side of the person.
  • Place the heel of one hand in the centre of the person's chest (the lower half of the sternum).
  • Place the heel of your other hand on top of the first hand.
  • Interlock the fingers of your hands and ensure that pressure is not applied over the person's ribs.
  • Keep your arms straight.
  • Do not apply any pressure over the upper abdomen or the distal end of the sternum.
  • Position your shoulders vertically above the person's chest and press the sternum down by 5–6 cm.
  • After each compression, release all the pressure on the chest without losing contact between your hands and the sternum.
  • Repeat at a rate of 100–120 times a minute (about two compressions a second).
  • If a crack is heard or felt during compressions (indicating a fracture to the costal cartilage or ribs) continue with chest compressions, having checked that your hands are in the correct position.
• Combine chest compressions with rescue breaths:
  • After 30 chest compressions, open the airway again — tilt their head back, lift the chin, and give two rescue breaths.
  • Pinch the soft part of the person's nose closed, using the index finger and thumb of the hand on their forehead.
  • Allow their mouth to open, but maintain the chin lift.
  • Take a normal breath and place your lips around the mouth, making sure that you have a good seal.
  • Blow steadily into the mouth whilst watching for the chest to rise. Take about 1 second to make the chest rise as in normal breathing — this is an effective rescue breath.
  • Maintain the head tilt and chin lift, take your mouth away and watch for the chest to fall as air comes out.
  • Take another normal breath and blow into the person's mouth once more to give a total of two effective rescue breaths.
    • Do not interrupt compression by more than 10 seconds to deliver two breaths.
  • Return your hands, without delay, to the correct position on the sternum and give a further 30 chest compressions.
  • Continue with chest compressions and rescue breaths in a ratio of 30:2.
  • If you are not trained to, or are unwilling to give rescue breaths, give chest compressions only.
• Do not interrupt resuscitation until:
  • A health professional tells you to stop.
  • You become exhausted — if another rescuer is present they may be able to take over.
    • If there are sufficient trained CPR providers, they should changeover every two minutes to prevent a decrease in compression quality, but chest compression should not be interrupted during this changeover.
  • The person is definitely waking up, moving, opening their eyes and breathing normally.
    • Note: It is rare for CPR alone to restart a normal heart rhythm, CPR should be continued unless it is certain that the person has recovered.

How should I use an automated external defibrillator?

• If an automated external defibrillator (AED) is available:
  • Switch it on and attach the electrode pads to the person's bare chest according to the directions shown on the AED device or the pads.
  • Continue cardiopulmonary resuscitation (CPR) while the electrode pads are being attached (if another rescuer is present).
  • Ensure that nobody touches the person while the AED analyses the rhythm.
  • Follow the spoken and visual instructions.
    • Push the shock button as directed (this may not be necessary if the AED is fully automated) — ensure that nobody is touching the person.
    • Restart CPR immediately at a ratio of 30:2, and continue to follow the AED instructions — the AED often allows for a period of 2 minutes CPR before a prompt for a pause in CPR for further rhythm analysis.
    • If no shock is indicated restart CPR immediately, and continue to follow the AED instructions.

How do I assess someone with a suspected cardiac arrest?

• For information on the assessment of people with suspected cardiac arrest, see the section on assessment.
  • If an automated external defibrillator (AED) is not available, use a manual defibrillator.
  • An algorithm for adult advanced life support is available on the Resuscitation Council (UK) website (www.resus.org.uk).

When should I attempt defibrillation?

• Continue CPR until a defibrillator is available.
• As soon as a defibrillator is available, assess the rhythm by applying self-adhesive patches to the chest.
  • Give uninterrupted chest compressions whilst patches are applied.
• If an automated external defibrillator is used, follow the spoken and visual instructions.
• If a manual defibrillator is used:
  • Attempt defibrillation if ventricular fibrillation (VF) or ventricular tachycardia (VT) is identified. Manage as shockable rhythm. 
  • Do not attempt defibrillation if asystole or pulseless electrical activity (PEA) is identified. Manage as non-shockable rhythm. 
    • PEA is defined as organized cardiac electrical activity in the absence of any palpable pulse. It may be caused by reversible conditions that can be treated if they are identified and corrected. Survival following cardiac arrest with asystole or PEA is unlikely unless a reversible cause can be found and treated effectively.
  • Do not attempt defibrillation if there is doubt about whether the rhythm is asystole or fine VF. Manage as non-shockable rhythm. 

How do I manage someone with a shockable rhythm (VF/VT)?

• Attempt defibrillation if ventricular fibrillation (VF) or ventricular tachycardia (VT) is identified.
  • Warn all rescuers, other than the person performing cardiopulmonary resuscitation (CPR), to stand clear and remove any oxygen delivery devices if appropriate.
  • Once the defibrillator is charged, tell the rescuer performing chest compressions to stand clear.
  • Follow the manufacturer's instructions when choosing the energy level for defibrillation.
    • If you are unsure of the correct energy level, choose the highest available energy.
    • If using an automated external defibrillator (AED), the unit will automatically choose the correct level for each shock.
• Immediately resume CPR after the first shock with a 30:2 ratio of compressions to rescue breaths without reassessing the rhythm or feeling for a pulse.
• Continue CPR for 2 minutes, then pause briefly (for no longer than 5 seconds) to check the monitor.
  • If VF/VT persists, continue chest compressions — warn all rescuers, other than the person performing CPR to stand clear and remove any oxygen delivery devices if appropriate.
  • Once the defibrillator is charged, tell the rescuer doing chest compressions to stand clear.
  • Give a further (second) shock.
• Resume CPR immediately and continue for 2 minutes, then pause briefly to check the monitor.
  • If VF/VT persists, resume chest compressions — warn all rescuers, other than the person performing CPR to stand clear and remove any oxygen delivery devices if appropriate.
  • Once the defibrillator is charged, tell the rescuer doing chest compressions to stand clear.
  • Give a third shock.
• Resume CPR immediately and then give adrenaline 1 mg intravenously (IV) and amiodarone 300 mg IV, while continuing CPR for a further 2 minutes.
  • Withhold adrenaline if there are signs of return of spontaneous circulation (ROSC) during CPR.
  • These doses should be varied for children experiencing cardiac arrest.
• Repeat the 2-minute CPR, rhythm/pulse check, and defibrillation sequence if VF/VT persists.
• Give further adrenaline 1 mg IV after alternate shocks (approximately every 3–5 minutes).
  • Consider a further dose of amiodarone 150 mg IV after five defibrillation attempts.
  • Lidocaine 100 mg IV may be used as an alternative if amiodarone is not available.
    • Lidocaine should not be given if amiodarone has already been administered.
    • Where lidocaine is used, consider an additional bolus of lidocaine 50 mg after five defibrillation attempts.
• If organized electrical activity is seen during a rhythm check, seek evidence of ROSC (for example, a central pulse or other signs of life).
  • If there is ROSC, start post-resuscitation care.
  • If there are no signs of ROSC, continue CPR and manage as non-shockable rhythm.
• If asystole is seen, continue CPR and manage as non-shockable rhythm.
• Consider possible reversible causes of cardiac arrest and correct any that are identified.

How do I manage someone with a non-shockable rhythm (asystole/PEA)?

• Start cardiopulmonary resuscitation (CPR) with a 30:2 ratio of compressions to rescue breaths for people with pulseless electrical activity (PEA) or asystole.
• Give adrenaline 1 mg intravenously (IV) as soon as venous access is achieved.
• Continue CPR (30:2) until the airway is secured — once the airway is secured, ventilate the lungs at a rate of about 10 breaths per minute and continue chest compressions without pausing during ventilation.
  • Use a supraglottic airway device (SAD), such as a laryngeal mask airway (LMA), or a tracheal tube for those with appropriate training and adequate experience.
    • Other devices include the i-gel, and the LMA Supreme (LMAS). 
  • If it is not possible to protect the airway (for example, due to the inexperience of rescuers, or available equipment) continue CPR with a 30:2 ratio of compressions to rescue breaths using a bag-mask until appropriately experienced or equipped people arrive.
• Recheck the person after 2 minutes.
  • If there is electrical activity compatible with a pulse, check for a pulse and/or signs of life.
  • If a pulse/and or signs of life are present, start post-resuscitation care.
  • If there is no pulse/and or signs of life: 
    • Continue CPR.
    • Recheck the rhythm after 2 minutes and proceed accordingly.
    • Give adrenaline 1 mg IV after every alternate sequence of CPR/rhythm check (approximately every 3–5 minutes). 
  • If the ECG shows ventricular fibrillation (VF) or ventricular tachycardia (VT), manage as for shockable rhythm.
• Consider possible reversible causes of cardiac arrest and correct any that are identified.

What resuscitation equipment should be available in primary care?

• As a minimum, the following resuscitation equipment should be available in every primary healthcare practice:
  • Gloves, apron, eye protection.
  • Oxygen cylinder, tubing and pocket mask (adult) with oxygen port. 
  • Automated external defibrillator (AED) with adhesive defibrillator pads (and a spare set of pads), razor (to shave the area intended for electrode placement), and an absorbent towel (to dry the chest if required). 
  • Stethoscope.
• For healthcare professionals with enhanced skills, or managing people at increased risk of cardiorespiratory arrest, the following equipment should also be available:
  • Portable suction.
  • Oropharyngeal airways (sizes 0–4).
  • Self-inflating bag with reservoir.
  • Clear face masks (sizes 0–4).
  • Supraglottic airway device with syringes, lubrication, ties, tapes, scissors.
  • ECG electrodes.
  • Intravenous cannulae and 2% chlorhexidine wipes, tourniquets and cannula dressings.
  • Adhesive tape.
  • Intravenous infusion set.
  • Sodium chloride 0.9% (2 x 100 ml).
  • Glucose 10% (500 ml).
  • Selection of needles and syringes.
  • Intraosseous access devices and/or needles for adults, children and infants.
  • IV extension set.
  • 50 ml syringes x 2. 
  • Adrenaline 1 mg as a prefilled syringe.
  • Algorithms, emergency drug doses and paediatric drug calculators.
  • Sharps container.
  • Glucose monitor.

How should I manage a person who has been resuscitated?

Initiate post-resuscitation care immediately once a return of spontaneous circulation (ROSC) has been achieved.

• For cardiac arrests which have occurred outside of hospital, this involves arranging the safe transfer of the person to a critical care environment.
• While awaiting transfer to secondary care, ensure: 
  • Continuous monitoring of the person.
  • Continued airway and ventilation support.
    • Use 100% (or maximum available) inspired oxygen until the arterial oxygen saturation can be measured reliably.
    • Avoid hyperoxaemia. 
  • Regular temperature monitoring for people who remain comatose after a ROSC, and actively prevent fever (>37.7°C).
    • Cooling methods could involve exposing the person or using simple ice packs with or without wet towels, cooling blankets or pads.
    • Intravenous cold fluids should not be used.
• Where available, consider performing a 12-lead ECG to assess for signs of ST-elevation myocardial infarction (STEMI).

When should I consider terminating resuscitation?

• No single factor should be used to determine when resuscitative efforts should be terminated.
• The decision to cease resuscitation attempts must balance:
  • The chances that ongoing resuscitation could achieve a return of spontaneous circulation (ROSC) and a beneficial outcome for the person who has experienced the cardiac arrest.
  • The risks and resources associated with continued resuscitation efforts.
  • Respect for human dignity.
• Unequivocal criteria for the termination of resuscitation efforts include instances where:
  • The safety of the resuscitation provider cannot be adequately assured.
  • There is obvious mortal injury or irreversible death.
  • A valid and relevant advanced decision against the provision of cardiopulmonary resuscitation (CPR) becomes available.
• In cases where these criteria are not present, the use of validated termination of resuscitation (TOR) rules is recommended.
• In cases where Basic Life Support (BLS) has been implemented, resuscitation may be terminated when all the following criteria are met:
  • The cardiac arrest was not witnessed by medical staff.
  • A ROSC was not established prior to attempted transport to secondary specialist care.
  • A defibrillator shock was not administered prior to attempted transport to secondary specialist care.
• In cases where Advanced Life Support (ALS) has been implemented, resuscitation may be terminated when all the following criteria are met:
  • The cardiac arrest was not witnessed by medical staff.
  • No bystander CPR was provided.
  • A ROSC was not established prior to attempted transport to secondary specialist care.
  • A defibrillator shock was not administered prior to attempted transport to secondary specialist care.
• Additional criteria which may be valuable for determining TOR include:
  • Persistent asystole despite at least 20 minutes of ALS in the absence of any reversible cause.
  • Unwitnessed cardiac arrest with an initial non-shockable rhythm where the risk of harm from ongoing CPR likely outweighs any benefit (e.g. severe chronic co-morbidities).
• In all cases where resuscitative efforts have been terminated, clinicians should clearly document the factors which influenced the decision to discontinue CPR.