PHWR Public Health Weekly Report

The incidence of out-of-hospital cardiac arrest (OHCA) in the Republic of Korea (ROK) has increased from 44.3 per 100,000 (21,905 cases) in 2008 to 64.7 per 100,000 (33,034 cases) in 2024. While the survival-to-discharge rate of patients with cardiac arrest has improved from 2.5% in 2008 to 9.2% in 2024, more than 90% of patients still die [1]. In 2024, 44.8% of OHCAs occurred at home, where the lack of immediate bystander intervention, such as cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED), could result in hypoxic brain injury. Therefore, not only advanced life support in hospitals but also rescue activities performed outside hospitals substantially impact the survival and neurological recovery of patients with cardiac arrest [2]. Therefore, several countries seek to improve OHCA survival rates by focusing on public education regarding appropriate measures, including actions during cardiac arrest situations, CPR techniques, and AED use. In addition, they are developing and disseminating CPR guidelines that can be applied in actual emergency settings.

CPR guidelines include not only treatment recommendations for healthcare professionals but also instructions for lay rescuers who witness a cardiac arrest and attempt to resuscitate the victim. In the ROK, the Korea Disease Control and Prevention Agency (KDCA) and the Korean Association of Cardiopulmonary Resuscitation (KACPR) jointly published the nation’s first Public CPR Guidelines in 2006, which went through three revisions to become the current version of “2020 Korean Guidelines for Cardiopulmonary Resuscitation” (2020 Guidelines) [3,4]. These guidelines are regularly updated to improve CPR practices by incorporating the latest scientific evidence from CPR-related research. To date, the revisions of the guidelines have led to updated CPR training programs and the implementation of current best practices in the field, thereby enhancing survival rates from cardiac arrest. Recently, the KDCA developed the “2025 Korean Guidelines for Cardiopulmonary Resuscitation” (2025 Guidelines) based on the latest scientific evidence on CPR and cardiac arrest management, which was presented at the 14th Acute Cardiac Arrest Survey Symposium on December 9, 2025. This report aims to introduce the revision process and the key contents of the 2025 Guidelines.

The revision of the 2025 Guidelines was conducted as a policy research project commissioned by the KDCA through the establishment of an overarching steering committee and domain-specific expert committees. The CPR guidelines are categorized by age group—adult, pediatric, and neonatal—with each further divided into four key domains: basic life support, which includes initial treatment by rescuers including laypersons; advanced life support, which includes advanced treatment by healthcare professionals; post–cardiac arrest care, which includes intensive care and rehabilitation after return of spontaneous circulation (ROSC); and CPR education and implementation. In addition, this revision included a new “Emergency First Aid” domain to address the management of conditions that could lead to cardiac arrest. To support these expanded areas, a total of seven expert committees were established: basic life support, advanced life support, post–cardiac arrest care, pediatric resuscitation, neonatal resuscitation, education and implementation, and emergency first aid. A total of 73 experts recommended by 16 professional organizations related to CPR, including the KACPR, participated in the evidence review and guideline drafting process. All individuals involved in guideline revision submitted conflict of interest declarations, disclosing any potential financial or intellectual conflicts related to CPR.

Each expert committee reviewed the contents of the international consensus on CPR guidelines published since 2020 by the International Liaison Committee on Resuscitation (ILCOR), as well as subsequently published research articles [5]. To conduct a systematic literature review of the items requiring revision, questions were developed using the Population, Intervention, Comparator, Outcome (PICO) framework. Two reviewers were assigned to each PICO question. A total of 64 PICO questions were ultimately selected, including 15, 12, 10, eight, six, eight, and five for basic life support, advanced life support, post–cardiac arrest care, pediatric resuscitation, neonatal resuscitation, education and implementation, and emergency first aid, respectively (Supplement; available online). For the systematic review, international databases such as PubMed, Embase, and Cochrane were utilized, while KoreaMed was employed for domestic literature searches.

Revision items were evaluated according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology based on the search results [6]. GRADE is an internationally used methodology for determining the strength of recommendations and the certainty of evidence in the development of clinical practice guidelines [7]. The certainty of evidence was classified into four levels: high, moderate, low, and very low. The strength of recommendations was categorized into four types based on direction (recommend or against) and intensity (strong or weak). These categories were determined by considering the balance of treatment effects, certainty of evidence, variability in patient values and preferences, and resource implications. Strong recommendations were made when the balance between desirable and undesirable effects was large and the certainty of evidence was high, whereas weak recommendations were made when there was substantial variability in values and preferences or when treatment costs were high. In cases where evidence was insufficient to support a formal recommendation, expert consensus recommendations or good practice statements were established through a consensus-based process.

After completion of the evidence review process, the reviewers submitted a draft of the Korean CPR clinical practice guideline statement to the expert committees in a standardized format that included the corresponding ILCOR recommendations, whether and why modifications were needed for application in the ROK, and proposed national recommendations. Discrepancies among reviewers or items requiring further consensus were deliberated and resolved through formal consensus meetings. Each expert committee drafted its respective guideline section, and a public forum was held to gather a wide range of expert opinions, which were incorporated to finalize the 2025 Guidelines (Figure 1).

Figure 1. Procedure for updating the 2025 Korean CPR guidelines
CPR=cardiopulmonary resuscitation; ILCOR=International Liaison Committee on Resuscitation; PICO=Population, Intervention, Comparator, Outcome; GRADE=Grading of Recommendations, Assessment, Development, and Evaluation.

The 2025 Guidelines were written across the domains of basic life support, advanced life support, post–cardiac arrest care, pediatric resuscitation, neonatal resuscitation, education and implementation, and emergency first aid. The major revised or newly described items are summarized below (Table 1).

Table 1 Summary of major changes in the 2025 CPR guidelines

Field	2020 CPR guidelines	2025 CPR guidelines	Note
Basic life support		Emergency medical dispatchers should instruct bystanders on obtaining and applying AEDs.	New
	A backboard should be positioned between the mattress and the patient’s back when performing chest compression.	Allow the use of existing backboards, but do not recommend introducing new backboards.	Update
		Rescuer’s dominant hand should be located downward when performing CPR.	New
	Perform ventilation every five to six seconds (10–12 breaths per minute).	Perform ventilation every six seconds (ten breaths per minute).	Update
		AED pads can be attached to the bare chest after adjusting the bra position of female patients undergoing cardiac arrest; there is no need to remove the undergarment.	New
	Insufficient evidence to support ventilation as the initial action for drowning patients.	Trained first responders or emergency medical providers should start with rescue breathing in drowning patients.	Update
Advanced life support		The routine use of calcium, buffers, and additional vasopressin and corticosteroids is not recommended.	New
	Routine use of double sequential defibrillation in shockable rhythm is not recommended.	In refractory ventricular fibrillation, trained healthcare providers should attempt double sequential or vector change defibrillation if spare pads or defibrillators are readily available.	Update
		CPR may be attempted in patients found in the prone position when endotracheal intubation is performed, and it is difficult or risky to immediately turn the patient to the supine position.	New
	Point-of-care ultrasound can be used to determine the cause of cardiac arrest or to ascertain whether the myocardium is contracting, if it does not interfere with CPR.	Point-of-care ultrasound is not routinely recommended; however, it may be used as a diagnostic tool for reversible causes of cardiac arrest, if executed by a skilled practitioner without interrupting CPR.	Update
		When available, extracorporeal CPR may be considered an elective rescue treatment if ROSC is not achieved through conventional CPR in adult patients.	New
Post-cardiac arrest care	Target temperature of 32–36°C is recommended for comatose patients after ROSC.	Target temperature of 33–37.5°C is suggested in comatose patients after ROSC.	Update
		Preferably, the utilized temperature control equipment should include a feedback system based on continuous temperature monitoring.	New
		Routine use of steroids in comatose patients after cardiac arrest is not recommended.	New
		Use highly malignant EEG patterns to predict poor neurological outcomes in comatose, sedated adult patients after cardiac arrest.	New
Pediatric/neonatal resuscitation	The two-finger method for one rescuer and the two-thumb encircling technique for two rescuers are recommended for infant chest compression.	The two-thumb encircling compression technique is recommended for infant chest compression, notwithstanding the number of rescuers.	Update
		The use of AEDs by laypersons is advised for children aged one year and older in instances of out-of-hospital cardiac arrest.	New
	One breath should be performed every six seconds (ten breaths per minute) in children with cardiac arrest after securing the advanced airway.	Age-appropriate ventilation rates are suggested for pediatric cardiac arrest patients after the advanced airway is secured (30 breaths/min for infants aged under one year, 20–30 breaths/min for one to eight-year-old children).	Update
		A target diastolic blood pressure is suggested (<1 year: 25 mmHg, >1 year: 30 mmHg or more) when pediatric patients with in-hospital cardiac arrest must undergo invasive arterial pressure measurement.	New
	There is insufficient evidence for early or delayed cord clamping in term or premature infants requiring resuscitation at birth.	Umbilical cord milking is advised before clamping in full-term and late premature infants (more than 34 gestational weeks) who are not vigorous at birth.	Update
		Supraglottic airway may be used instead of a face mask when positive pressure ventilation is required for full-term infants or late premature infants (more than 34 gestational weeks) who require immediate resuscitation at birth.	New
Pediatric/neonatal resuscitation		A video laryngoscope should be used during endotracheal intubation instead of a conventional laryngoscope, if resources and training permit.	New
	The decision to discontinue CPR can be considered approximately ten to 20 minutes after birth.	The decision to discontinue CPR can be considered approximately 20 minutes after birth.	Update
Education/implementation	Resuscitation team members should participate in advanced life support training.	When forming an in-hospital CPR team, team members who have received advanced life support training should be included.	Update
	The use of feedback devices is suggested in resuscitation training.	The use of feedback devices in resuscitation training is recommended.	Update
	The use of virtual reality, augmented reality, and web-based untact learning platforms may be considered when face-to-face learning is not possible.	Self-directed, non-face-to-face learning as implemented during the pandemic should not be routinely recommended.	Update
General	Separate chain of survival for adults, children, and out-of-hospital and in-hospital cardiac arrest cases.	Single chain of survival: recognition∙EMS activation ― bystander CPR, defibrillation, advanced life support∙postcardiac arrest care ― rehabilitation∙recovery.	Update

CPR=cardiopulmonary resuscitation; AED=automated external defibrillator; ROSC=return of spontaneous circulation; EMS=emergency medical service; EEG=electroencephalogram..

1. Basic Life Support

The chains of survival that had previously been proposed separately for adult, pediatric, OHCA, and in-hospital cardiac arrest were integrated into a single, simplified model. The 2025 chain of survival maintains a five-link structure, but with significant updates: advanced life support and post–cardiac arrest care have been integrated into a single link, while rehabilitation and recovery are now highlighted as a distinct fifth link. Accordingly, the chain is defined as follows: 1) recognition of cardiac arrest and activation of emergency response, 2) bystander CPR, 3) defibrillation, 4) advanced life support and post–cardiac arrest care, and 5) rehabilitation and recovery.

The existing guideline recommending that the witnesses of a cardiac arrest perform chest compressions with telephonic assistance from emergency medical dispatchers was expanded to include instructions on the retrieval and application of an AED. This guideline takes into account the low rate of bystander defibrillation in the ROK. For female cardiac arrest patients, considering that the removal of undergarments may delay AED application, it is recommended to adjust the position of the AED pads rather than unfastening or removing the brassiere. Although the sequence of CPR had previously been standardized to begin with chest compressions to facilitate training, for cardiac arrest due to drowning, the revision was made to allow trained rescuers to initiate CPR with rescue breathing. Previous CPR sequence and techniques were maintained, with the additional instruction that the rescuer’s dominant (comfortable) hand be placed on the bottom when interlocking the hands during chest compressions.

2. Advanced Life Support

For patients with refractory ventricular fibrillation, the revision recommends that trained healthcare professionals attempt double sequential defibrillation or vector-change defibrillation if an additional defibrillator is available. When performing double sequential external defibrillation, it is recommended that a single operator activates both defibrillators sequentially to achieve the optimal timing between shocks. The additional administration of vasopressin and corticosteroids alongside standard epinephrine therapy is not recommended during CPR for patients undergoing cardiac arrest. Point-of-care ultrasound is not recommended for routine use during CPR; however, if performed by a skilled operator without interrupting resuscitation efforts, it could be used to identify potentially reversible causes of cardiac arrest. If ROSC is not achieved through standard CPR, extracorporeal CPR may be considered in medical institutions equipped with the necessary resources and expert personnel.

3. Post–Cardiac Arrest Care

Targeted temperature management (temperature control) is recommended for comatose patients who achieved ROSC after cardiac arrest. In this case, the target temperature range is revised from 32–36°C to 33–37.5°C. In cases where temperature control devices are used, equipment with feedback systems allowing continuous temperature monitoring is recommended. Routine use of corticosteroids is not recommended in comatose adult patients after cardiac arrest. Additional indicators for predicting favorable and unfavorable neurological outcomes in comatose patients after cardiac arrest are described.

4. Pediatric and Neonatal Resuscitation

While bystander defibrillation was previously recommended only for adults, the eligibility for AED use has been extended to include children aged 1 year and older. For pediatric cardiac arrest patients with an advanced airway in place, ventilations should be provided at age-appropriate rates (under 1 year: 30 breaths per minute, 1–8 years: 20–30 breaths per minute). In infants and children who achieved ROSC after cardiac arrest, the target systolic blood pressure during the first 6 hours has been set to exceed the age-specific 10th percentile.

The revision outlines comprehensive protocols for neonatal umbilical cord management, tailored to specific clinical circumstances. For example, in term infants and late preterm infants of gestational age 34 weeks or greater who were not vigorous immediately after birth, umbilical cord milking before cord clamping is recommended. Where resources and training permit, supraglottic airway devices and video laryngoscopy are recommended for use in neonates.

5. Education and Implementation

During resuscitation training, the use of devices that provide feedback on chest compression depth, rate, and correct hand position through voice prompts or a metronome is recommended. The guidelines recommend that in-hospital resuscitation teams be composed of members certified or trained in Advanced Life Support to ensure high-quality care. The routine implementation of self-directed, asynchronous online learning—widely adopted during pandemic-era social distancing—is no longer recommended as a standard substitute for traditional training.

6. Emergency First Aid

Emergency first aid is included for the first time in the 2025 Guidelines. However, CPR guidelines from the United States and Europe, as well as those issued by ILCOR, include first aid guidance as part of efforts to prevent progression to cardiac arrest. Although the scope of first aid ranges from minor conditions to life-threatening situations, 2025 Korean guideline selected several emergency conditions that may be associated with cardiac arrest and described interventions that can be performed by laypersons.

For patients experiencing chest pain, assisting with the administration of the previously prescribed nitroglycerin, whether in tablet or sublingual spray form, is recommended. The use of various screening tools to facilitate early recognition of suspected acute stroke is recommended. If a patient recognizes an asthma attack and has their personal inhaler available, it is recommended that rescuers provide assistance with its administration. When a person at risk of anaphylaxis requests help, it is advised that the first aid providers assist with the use of an epinephrine auto-injector, and maintaining an appropriate position is recommended for patients suspected of being in shock.

To improve survival rates for OHCA, many countries—including the United States and those in Europe—develop and implement CPR guidelines that incorporate the latest scientific evidence while accounting for their specific emergency medical systems, cultural contexts, and socio-ethical, legal, and institutional considerations. The revision of CPR guidelines extends beyond a mere update of scientific evidence; it aims to catalyze transformative changes in the socio-medical environment, ultimately enhancing the survival rates of patients undergoing cardiac arrest. In this report, the major revisions made in the 2025 Guidelines are briefly introduced. Due to space limitations, the detailed evidence supporting these revisions has been omitted. Readers are encouraged to refer to the full version of the 2025 Guidelines, which is available online for more comprehensive information.

CPR techniques are widely disseminated through schools, the National Fire Agency, and other relevant organizations, describing standardized training programs developed by the KDCA and KACPR. Consequently, any citizen interested in CPR training can access programs through various accredited institutions, including metropolitan and provincial fire headquarters, local fire stations, public health centers, the Korean Red Cross, the Korean Council for CPR (www.kcn.or.kr), and the Korean Association of CPR (www.kacpr.org). The 2025 Guidelines are set for release on the KDCA website in January 2026. Following this release, various initiatives to disseminate the revisions, including the publication of guideline booklets and the development of new CPR educational materials, are expected to commence.

Ethics Statement: Not applicable.

Funding Source: This project was supported by the Korea Disease Control and Prevention Agency (2024100BE7B-00).

Acknowledgments: None.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Conceptualization: SPC, SOH. Data curation: DKK, TYK, YDS, GHS, YHJ, YHO, CSY, JSL, CHL, YBJ, YSJ, GCC, KCC, JSH. Funding acquisition: SPC. Investigation: DKK, TYK, YDS, GHS, YHJ, YHO, CSY, JSL, CHL, YBJ, YSJ, GCC, KCC, JSH. Methodology: SPC, SOH. Project administration: JSK, JEL, EHJ. Supervision: SOH, EHJ. Validation: YBJ. Writing – original draft: SPC. Writing – review & editing: DKK, TYK, YDS, GHS, YHJ, YHO, CSY, MJL, JSL, CHL, YBJ, YSJ, GCC, KCC, JSH.

Supplementary data are available online.