2020 Korean Cardiopulmonary Resuscitation Guidelines

Sung Oh Hwang; Kyoung-chul Cha; Sung Phil Chung; Young-Min Kim; June Dong Park; Han-Suk Kim; Mi Jin Lee; Sang-Hoon Na; Gyu Chong Cho; Ai-Rhan Ellen Kim; Hajung Yoon; Sanghui Kweon

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Epidemiology and Surveillance

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Public Health Weekly Report 2021; 14(7): 358-369

Published online February 10, 2021

2020 Korean Cardiopulmonary Resuscitation Guidelines

Hwang Sung Oh¹, Cha Kyoung-chul¹, Chung Sung Phil², Kim Young-Min³, Park June Dong⁴, Kim Han-Suk⁴, Lee Mi Jin⁵, Na Sang-Hoon⁶, Cho Gyu Chong⁷, Kim Ai-Rhan Ellen⁸, Yoon Hajung⁹, Kweon Sanghui¹⁰

¹Department of Emergency Medicine, Yonsei University Wonju College of Medicine
²Department of Emergency Medicine, Yonsei University College of Medicine
³Department of Internal Medicine, The Catholic University of Korea College of Medicine
⁴Department of Pediatrics, Seoul National University College of Medicine
⁵Department of Emergency Medicine, Kyoungbook University College of Medicine
⁶Department of Internal Medicine, Seoul National University College of Medicine
⁷Department of Emergency Medicine, Hallym University College of Medicine
⁸Department of Pediatrics, Ulsan University College of Medicine
⁹Division of Chronic Disease Investigation, Chungcheong Regional Center for Disease Control and Prevention (RCDC), Korea Disease Control and Prevention Agency (KDCA)
¹⁰Division of Injury Prevention and Control, Bureau of Health Hazard Response, Korea Disease Control and Prevention Agency (KDCA)

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Cardiopulmonary resuscitation (CPR) guidelines are a set of medical recommendations for cardiac arrest treatment based on scientific evidence. Korea has been updating its CPR guidelines every five years since the first CPR guidelines were established in 2006 by the Korean Association of CPR. The aim of this paper is to introduce the 2020 Korean CPR Guidelines. Findings indicated that the major changes included: 1) the concept of the environment for cardiac arrest survival and the new chain of survival; 2) the enhanced role of the emergency medical dispatcher in recognizing cardiac arrest and providing CPR through witnesses; 3) modification of priority in the maneuvers for managing foreign body airway obstruction; 4) recommendations for the duration of on-site CPR; 5) new recommendations for advanced airway management, drugs, and pediatric defibrillation energy; 6) new recommendations for target temperature management, emergency coronary angiography, neurological prognostication, and rehabilitation of cardiac arrest survivors; 7) new recommendations for encouragement to monitor the quality of cardiac arrest treatment performance; 8) new recommendations for using social media; 9) new education processes, and 10) guidelines for CPR for patients with coronavirus disease (COVID-19) or those suspected infection. We plans to develop training programs and distribute the guidelines for public use based on the 2020 Korean CPR guidelines were recommended.

Key words Cardiopulmonary resuscitation, Guidelines, Cardiac arrest, Education, Implementation

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Reference

Table 1. Summary table of major changes in the 2020 CPR guidelines compared to the 2015 CPR guidelines

Discipline	2015 CPR guidelines	2020 CPR guidelines
Basic life support	Sequence of CPR (C-A-B): Chest compression-Airway-Breathing Depth of chest compressions: approximately 5cm(not exceeding 6cm) for adults, 4~5cm for children, 4cm for infants Rate of chest compressions: 100~120/min Ratio of compression and ventilation = 30:2	Sequence of CPR (C-A-B): Chest compression-Airway-Breathing Depth of chest compressions: approximately 5 cm (not exceeding 6 cm) for adults, 4-5 cm for children, 4cm for infants Rate of chest compressions: 100~120/min Ratio of compression and ventilation = 30:2	No change
	Recommend moving the patient from bed to floor to increase the depth of chest compression	Recommend not moving the patient from bed to floor to increase the depth of chest compression	Updated
	An abdominal thrust as the first maneuver for a patient with foreign body airway obstruction and ineffective coughing effort	A back blow as the first maneuver for a patient with foreign body airway obstruction and ineffective coughing effort	Updated
		Emergency medical dispatchers should assist the bystander in performing cardiac arrest and perform dispatcher-assisted telephone CPR by using standard protocols during an emergency phone call	Updated
		CPR is recommended if cardiac arrest is suspected because the possibility of complications is small	New
		CPR guidelines for cardiac arrest victims with coronavirus infection or suspected infection are provided	New
Advanced life support		Emergency medical personnel should choose either a bag-mask or an advanced airway (endotracheal intubation or supraglottal airway) during resuscitation	New
		Only emergency medical personnel with sufficient training and experience may perform endotracheal intubation	New
	Lidocaine can be used as an alternative for amiodarone in treating refractory ventricular fibrillation	Amiodarone and lidocaine are equally recommended as antiarrhythmic drugs for the treatment of refractory ventricular fibrillation	Updated
		End tidal CO2 monitoring and point-of-care ultrasonography can be used for monitoring the patient during advanced life support	New
		Extracoporeal CPR is recommended in selective patients when effort to restore spontaneous circulation with standard CPR fails	New
Post-cardiac arrest care	Emergency coronary angiography is indicated in patients with cardiac arrest from cardiac etiology	Emergency coronary angiography is indicated in patients with cardiac arrest with ST-segment elevation on EKG	Updated
	Targeted temperature management is strongly recommended for patients resuscitated from shockable rhythm	Targeted temperature management is strongly recommended for patients resuscitated from both shockable rhythm and non-shockable rhythm	Updated
	Early cooling with cold saline infusion outside the hospital or emergency room is indicated for patients resuscitated from cardiac arrest	Early cooling with cold saline infusion should not be performed on patients resuscitated from cardiac arrest	Updated
		Prophylactic antibiotic administration is not recommended during post-cardiac arrest period	New
	Neurological prognostication can be performed 72h after restoration of spontaneous circulation	Neurological prognostication can be performed 5 days after restoration of spontaneous circulation	Updated
		A structured screening and assessment of physical and psychological disabilities is recommended for survivors of cardiac arrest A comprehensive, multidisciplinary discharge plan, including rehabilitation treatment, needs to be established for survivors of cardiac arrest	New
		It is necessary to designate a cardiac arrest center that can perform 24h coronary angiography, targeted temperature management, and tests for neurological prognostication	New
Pediatric life support/neonatal resuscitation	2-4 J/kg is indicated as the first defibrillation energy for children.	2 J/kg is indicated as the first defibrillation energy for children	Updated
		Epinephrine is indicated if the newborn has a heart rate of less than 60	New
		If umbilical vein is not available in newborns, intraosseous route is recommended as an alternative method	New
Education/implementation		Contacting volunteers with prior consent using social media is proposed to increase bystander CPR rate	New
		It is recommended to manage the CPR experience of emergency medical personnel and include those who have experienced resuscitation when forming a resuscitation team	New
		It is recommended to operate a rapid response team in hospitals	New
		Medical institutions and communities are encouraged to monitor the quality of cardiac arrest treatment performance	New
		It is recommended to develop a non-face-to-face CPR education program during an infectious disease epidemic/pandemic	New
		Recommendations for termination of resuscitation are provided	New
General	Chain of survival: Prevention of cardiac arrest and early recognition - rapid EMS activation - early CPR - early defibrillation - effective advanced life support and post-resuscitation care	Chain of survival for out-of-hospital cardiac arrest: Recognition and EMS activation - bystander CPR – defibrillation - advanced life support - post-cardiac arrest care Chain of survival for in-hospital cardiac arrest: Recognition and resuscitation team activation – high-quality CPR – defibrillation - advanced life support - post-cardiac arrest care	Updated
		Concept of environment for cardiac arrest survival, including prevention of cardiac arrest, CPR education, cardiac arrest treatment system, and quality improvement, is proposed	New
	CPR algorithms for lay people and healthcare providers are presented	Out-of-hospital cardiac arrest and in-hospital cardiac arrest algorithms for lay people and healthcare providers are presented	Updated
		On-site CPR is recommended for 6 minutes for basic resuscitation teams and up to 10 minutes for advanced resuscitation teams before transferring the patient to a hospital	New

Figure 1. The update process of the 2020 Korean CPR guidelines
PICO, population, intervention, comparator, outcome; ILCOR, International Liaison Committee on Resuscitation; CoSTR, Consensus on Science and Treatment
Recommendations; CPR, cardiopulmonary resuscitation

References

Sections

Abstract
Reference

질병관리청소방청. 2006-2019 급성심장정지조사 통계 (2020).
송근정, 김재범 김진희 등. 2015 심폐소생술 가이드라인 기본소생술전문위원회. 2015 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 제2부:기본소생술. 대한심폐소생협회.
공용 심폐소생술 가이드라인의 개발 및 배포, 보건복지부 중앙응급 의료센터, 대한심폐소생협회, 2006.
질병관리본부대한심폐소생협회. 2015년 한국형 심폐소생술 가이드 라인. 2015.
Olasveengen TM, de Caen AR, Mancini ME, et al. 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary. Resuscitation 2017;121:201-14.
Nolan JP, Maconochie I, Soar J, et al. Executive Summary 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020;156:A1-a22.
Schünemann H, Guyatt G, Oxman A, editors. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from guidelinedevelopment.org/handbook. 2013.

Epidemiology and Surveillance

Public Health Weekly Report 2021; 14(7): 358-369

Published online February 10, 2021

2020 Korean Cardiopulmonary Resuscitation Guidelines

Abstract

Keywords: Cardiopulmonary resuscitation, Guidelines, Cardiac arrest, Education, Implementation

Body

Table 1 Summary table of major changes in the 2020 CPR guidelines compared to the 2015 CPR guidelines

Discipline	2015 CPR guidelines	2020 CPR guidelines
Basic life support	Sequence of CPR (C-A-B): Chest compression-Airway-Breathing. Depth of chest compressions: approximately 5cm(not exceeding 6cm) for adults, 4~5cm for children, 4cm for infants. Rate of chest compressions: 100~120/min. Ratio of compression and ventilation = 30:2.	Sequence of CPR (C-A-B): Chest compression-Airway-Breathing. Depth of chest compressions: approximately 5 cm (not exceeding 6 cm) for adults, 4-5 cm for children, 4cm for infants. Rate of chest compressions: 100~120/min. Ratio of compression and ventilation = 30:2.	No change
	Recommend moving the patient from bed to floor to increase the depth of chest compression.	Recommend not moving the patient from bed to floor to increase the depth of chest compression.	Updated
	An abdominal thrust as the first maneuver for a patient with foreign body airway obstruction and ineffective coughing effort.	A back blow as the first maneuver for a patient with foreign body airway obstruction and ineffective coughing effort.	Updated
		Emergency medical dispatchers should assist the bystander in performing cardiac arrest and perform dispatcher-assisted telephone CPR by using standard protocols during an emergency phone call.	Updated
		CPR is recommended if cardiac arrest is suspected because the possibility of complications is small.	New
		CPR guidelines for cardiac arrest victims with coronavirus infection or suspected infection are provided.	New
Advanced life support		Emergency medical personnel should choose either a bag-mask or an advanced airway (endotracheal intubation or supraglottal airway) during resuscitation.	New
		Only emergency medical personnel with sufficient training and experience may perform endotracheal intubation.	New
	Lidocaine can be used as an alternative for amiodarone in treating refractory ventricular fibrillation.	Amiodarone and lidocaine are equally recommended as antiarrhythmic drugs for the treatment of refractory ventricular fibrillation.	Updated
		End tidal CO2 monitoring and point-of-care ultrasonography can be used for monitoring the patient during advanced life support.	New
		Extracoporeal CPR is recommended in selective patients when effort to restore spontaneous circulation with standard CPR fails.	New
Post-cardiac arrest care	Emergency coronary angiography is indicated in patients with cardiac arrest from cardiac etiology.	Emergency coronary angiography is indicated in patients with cardiac arrest with ST-segment elevation on EKG.	Updated
	Targeted temperature management is strongly recommended for patients resuscitated from shockable rhythm.	Targeted temperature management is strongly recommended for patients resuscitated from both shockable rhythm and non-shockable rhythm.	Updated
	Early cooling with cold saline infusion outside the hospital or emergency room is indicated for patients resuscitated from cardiac arrest.	Early cooling with cold saline infusion should not be performed on patients resuscitated from cardiac arrest.	Updated
		Prophylactic antibiotic administration is not recommended during post-cardiac arrest period.	New
	Neurological prognostication can be performed 72h after restoration of spontaneous circulation.	Neurological prognostication can be performed 5 days after restoration of spontaneous circulation.	Updated
		A structured screening and assessment of physical and psychological disabilities is recommended for survivors of cardiac arrest. A comprehensive, multidisciplinary discharge plan, including rehabilitation treatment, needs to be established for survivors of cardiac arrest.	New
		It is necessary to designate a cardiac arrest center that can perform 24h coronary angiography, targeted temperature management, and tests for neurological prognostication.	New
Pediatric life support/neonatal resuscitation	2-4 J/kg is indicated as the first defibrillation energy for children..	2 J/kg is indicated as the first defibrillation energy for children.	Updated
		Epinephrine is indicated if the newborn has a heart rate of less than 60.	New
		If umbilical vein is not available in newborns, intraosseous route is recommended as an alternative method.	New
Education/implementation		Contacting volunteers with prior consent using social media is proposed to increase bystander CPR rate.	New
		It is recommended to manage the CPR experience of emergency medical personnel and include those who have experienced resuscitation when forming a resuscitation team.	New
		It is recommended to operate a rapid response team in hospitals.	New
		Medical institutions and communities are encouraged to monitor the quality of cardiac arrest treatment performance.	New
		It is recommended to develop a non-face-to-face CPR education program during an infectious disease epidemic/pandemic.	New
		Recommendations for termination of resuscitation are provided.	New
General	Chain of survival: Prevention of cardiac arrest and early recognition - rapid EMS activation - early CPR - early defibrillation - effective advanced life support and post-resuscitation care.	Chain of survival for out-of-hospital cardiac arrest: Recognition and EMS activation - bystander CPR – defibrillation - advanced life support - post-cardiac arrest care. Chain of survival for in-hospital cardiac arrest: Recognition and resuscitation team activation – high-quality CPR – defibrillation - advanced life support - post-cardiac arrest care.	Updated
		Concept of environment for cardiac arrest survival, including prevention of cardiac arrest, CPR education, cardiac arrest treatment system, and quality improvement, is proposed.	New
	CPR algorithms for lay people and healthcare providers are presented.	Out-of-hospital cardiac arrest and in-hospital cardiac arrest algorithms for lay people and healthcare providers are presented.	Updated
		On-site CPR is recommended for 6 minutes for basic resuscitation teams and up to 10 minutes for advanced resuscitation teams before transferring the patient to a hospital.	New

Abstract
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Figure 1.The update process of the 2020 Korean CPR guidelines
PICO, population, intervention, comparator, outcome; ILCOR, International Liaison Committee on Resuscitation; CoSTR, Consensus on Science and Treatment
Recommendations; CPR, cardiopulmonary resuscitation

Public Health Weekly Report 2021; 14: 358-369

Table 1 Summary table of major changes in the 2020 CPR guidelines compared to the 2015 CPR guidelines

Discipline	2015 CPR guidelines	2020 CPR guidelines
Basic life support	Sequence of CPR (C-A-B): Chest compression-Airway-Breathing. Depth of chest compressions: approximately 5cm(not exceeding 6cm) for adults, 4~5cm for children, 4cm for infants. Rate of chest compressions: 100~120/min. Ratio of compression and ventilation = 30:2.	Sequence of CPR (C-A-B): Chest compression-Airway-Breathing. Depth of chest compressions: approximately 5 cm (not exceeding 6 cm) for adults, 4-5 cm for children, 4cm for infants. Rate of chest compressions: 100~120/min. Ratio of compression and ventilation = 30:2.	No change
	Recommend moving the patient from bed to floor to increase the depth of chest compression.	Recommend not moving the patient from bed to floor to increase the depth of chest compression.	Updated
	An abdominal thrust as the first maneuver for a patient with foreign body airway obstruction and ineffective coughing effort.	A back blow as the first maneuver for a patient with foreign body airway obstruction and ineffective coughing effort.	Updated
		Emergency medical dispatchers should assist the bystander in performing cardiac arrest and perform dispatcher-assisted telephone CPR by using standard protocols during an emergency phone call.	Updated
		CPR is recommended if cardiac arrest is suspected because the possibility of complications is small.	New
		CPR guidelines for cardiac arrest victims with coronavirus infection or suspected infection are provided.	New
Advanced life support		Emergency medical personnel should choose either a bag-mask or an advanced airway (endotracheal intubation or supraglottal airway) during resuscitation.	New
		Only emergency medical personnel with sufficient training and experience may perform endotracheal intubation.	New
	Lidocaine can be used as an alternative for amiodarone in treating refractory ventricular fibrillation.	Amiodarone and lidocaine are equally recommended as antiarrhythmic drugs for the treatment of refractory ventricular fibrillation.	Updated
		End tidal CO2 monitoring and point-of-care ultrasonography can be used for monitoring the patient during advanced life support.	New
		Extracoporeal CPR is recommended in selective patients when effort to restore spontaneous circulation with standard CPR fails.	New
Post-cardiac arrest care	Emergency coronary angiography is indicated in patients with cardiac arrest from cardiac etiology.	Emergency coronary angiography is indicated in patients with cardiac arrest with ST-segment elevation on EKG.	Updated
	Targeted temperature management is strongly recommended for patients resuscitated from shockable rhythm.	Targeted temperature management is strongly recommended for patients resuscitated from both shockable rhythm and non-shockable rhythm.	Updated
	Early cooling with cold saline infusion outside the hospital or emergency room is indicated for patients resuscitated from cardiac arrest.	Early cooling with cold saline infusion should not be performed on patients resuscitated from cardiac arrest.	Updated
		Prophylactic antibiotic administration is not recommended during post-cardiac arrest period.	New
	Neurological prognostication can be performed 72h after restoration of spontaneous circulation.	Neurological prognostication can be performed 5 days after restoration of spontaneous circulation.	Updated
		A structured screening and assessment of physical and psychological disabilities is recommended for survivors of cardiac arrest. A comprehensive, multidisciplinary discharge plan, including rehabilitation treatment, needs to be established for survivors of cardiac arrest.	New
		It is necessary to designate a cardiac arrest center that can perform 24h coronary angiography, targeted temperature management, and tests for neurological prognostication.	New
Pediatric life support/neonatal resuscitation	2-4 J/kg is indicated as the first defibrillation energy for children..	2 J/kg is indicated as the first defibrillation energy for children.	Updated
		Epinephrine is indicated if the newborn has a heart rate of less than 60.	New
		If umbilical vein is not available in newborns, intraosseous route is recommended as an alternative method.	New
Education/implementation		Contacting volunteers with prior consent using social media is proposed to increase bystander CPR rate.	New
		It is recommended to manage the CPR experience of emergency medical personnel and include those who have experienced resuscitation when forming a resuscitation team.	New
		It is recommended to operate a rapid response team in hospitals.	New
		Medical institutions and communities are encouraged to monitor the quality of cardiac arrest treatment performance.	New
		It is recommended to develop a non-face-to-face CPR education program during an infectious disease epidemic/pandemic.	New
		Recommendations for termination of resuscitation are provided.	New
General	Chain of survival: Prevention of cardiac arrest and early recognition - rapid EMS activation - early CPR - early defibrillation - effective advanced life support and post-resuscitation care.	Chain of survival for out-of-hospital cardiac arrest: Recognition and EMS activation - bystander CPR – defibrillation - advanced life support - post-cardiac arrest care. Chain of survival for in-hospital cardiac arrest: Recognition and resuscitation team activation – high-quality CPR – defibrillation - advanced life support - post-cardiac arrest care.	Updated
		Concept of environment for cardiac arrest survival, including prevention of cardiac arrest, CPR education, cardiac arrest treatment system, and quality improvement, is proposed.	New
	CPR algorithms for lay people and healthcare providers are presented.	Out-of-hospital cardiac arrest and in-hospital cardiac arrest algorithms for lay people and healthcare providers are presented.	Updated
		On-site CPR is recommended for 6 minutes for basic resuscitation teams and up to 10 minutes for advanced resuscitation teams before transferring the patient to a hospital.	New

References

질병관리청소방청. 2006-2019 급성심장정지조사 통계 (2020).
송근정, 김재범 김진희 등. 2015 심폐소생술 가이드라인 기본소생술전문위원회. 2015 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 제2부:기본소생술. 대한심폐소생협회.
공용 심폐소생술 가이드라인의 개발 및 배포, 보건복지부 중앙응급 의료센터, 대한심폐소생협회, 2006.
질병관리본부대한심폐소생협회. 2015년 한국형 심폐소생술 가이드 라인. 2015.
Olasveengen TM, de Caen AR, Mancini ME, et al. 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary. Resuscitation 2017;121:201-14.
Nolan JP, Maconochie I, Soar J, et al. Executive Summary 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020;156:A1-a22.
Schünemann H, Guyatt G, Oxman A, editors. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from guidelinedevelopment.org/handbook. 2013.