European Resuscitation Council Guidelines 2021:
Executive summary
GavinD.Perkinsa,b,*, Jan-ThorsenGraesnerc,FedericoSemerarod,
TheresaOlasveengene,Jasmeet Soarf,Carsten Lottg,PatrickVande Voordeh,i, JohnMadarj,DavidZidemank,Spyridon Mentzelopoulosl,LeoBossaertm,
RobertGreifn,o,KoenMonsieursp,HildigunnurSvavarsdo´ttirq,r,JerryP.Nolana,s, onbehalf oftheEuropeanResuscitation Council GuidelineCollaborators1
aWarwickClinicalTrialsUnit,WarwickMedicalSchool,UniversityofWarwick,CoventryCV47AL,UK
bUniversityHospitalsBirmingham,Birmingham,B95SS,UK
cUniversityHospitalSchleswig-Holstein,InstituteforEmergencyMedicine,Kiel,Germany
dDepartmentofAnaesthesia,IntensiveCareandEmergencyMedicalServices,MaggioreHospital,Bologna,Italy
eDepartmentofAnesthesiology,OsloUniversityHospitalandInstituteofClinicalMedicine,UniversityofOslo,Norway
fSouthmeadHospital,NorthBristolNHSTrust,Bristol,BS105NB,UK
gDepartmentofAnesthesiology,UniversityMedicalCenter,JohannesGutenberg-UniversityMainz,Germany
hDepartmentofEmergencyMedicine,FacultyofMedicineGhentUniversity,Ghent,Belgium
iEMSDispatchCenter,East-WestFlanders,FederalDepartmentofHealth,Belgium
jDepartmentofNeonatology,UniversityHospitalsPlymouth,Plymouth,UK
kThamesValleyAirAmbulance,Stokenchurch,UK
lNationalandKapodistrianUniversityofAthensMedicalSchool,Athens,Greece
mUniversityofAntwerp,Antwerp,Belgium
nDepartmentofAnaesthesiologyandPainMedicine,BernUniversityHospital,UniversityofBern,Bern,Switzerland
oSchoolofMedicine,SigmundFreudUniversityVienna,Vienna,Austria
pDepartmentofEmergencyMedicine,AntwerpUniversityHospitalandUniversityofAntwerp,Belgium
qAkureyriHospital,Akureyri,Iceland
rUniversityofAkureyri,Akureyri,Iceland
sRoyalUnitedHospital,BathBA13NG,UK
Abstract
Informedbyaseriesofsystematicreviews,scopingreviewsandevidenceupdatesfromtheInternationalLiaisonCommitteeonResuscitation,the2021 EuropeanResuscitationCouncilGuidelinespresentthemostuptodateevidence-basedguidelinesforthepracticeofresuscitationacrossEurope.The guidelinescovertheepidemiologyofcardiacarrest;therolethatsystemsplayinsavinglives,adultbasiclifesupport,adultadvancedlifesupport, resuscitationinspecialcircumstances,postresuscitationcare,firstaid,neonatallifesupport,paediatriclifesupport,ethicsandeducation.
Introduction
TheEuropeanResuscitationCouncil(ERC)objectiveistopreserve humanlifebymakinghighqualityresuscitationavailabletoall.1This
includesproducingup-to-dateevidence-basedEuropeanguidelines forthepreventionandtreatmentofcardiacarrestandlifethreatening emergencies.
ThefirstERCguidelineswerepresentedinBrightonin1992and coveredbasic2andadvancedlifesupport.3In1994,Guidelinesfor
* Correspondingauthor.
E-mailaddress:g.d.perkins@warwick.ac.uk(G.D. Perkins).
1 SeeAppendixA.
https://doi.org/10.1016/j.resuscitation.2021.02.003 Availableo
0300-9572/©2021EuropeanResuscitationCouncil.PublishedbyElsevierB.V.Allrightsreserved
Please citethisarticlein pressas: G.D.Perkins,etal., European ResuscitationCouncilGuidelines2021: Executivesummary, Availableonlineatwww.sciencedirect.com
Resuscitation
j our na lho me pa g e :ww w. e l s e v i e r. c om/ l o ca t e / re s usc i ta t i on
PaediatricLifeSupport(PLS)4andGuidelinesfortheManagementof Peri-arrestArrhythmias5followedatthesecondCongressinMainz, with Guidelines for theBasic and Advanced Managementof the AirwayandVentilationduringResuscitationatthethirdCongressin Seville in 1996,6 and updated Guidelines at the 4th Scientific CongressoftheERCinCopenhagenin1998.7,8In2000,international guidelines were produced in collaboration with the International LiaisonCommitteeonResuscitation(ILCOR)9whichtheERCwenton tosummarisein2001.10Afterthis,ERCguidelineswereproduced every5years:2005,11201012and2015.13From2017theERChas publishedannualupdates14,15 linkedtothepublicationsofILCOR ConsensusonScienceandTreatmentRecommendation(CoSTR) publications.16,17 In 2020, guidelines were published covering resuscitationin thecontextof coronavirusdisease2019(COVID- 19).18 These 2021 ERC Guidelines present a major update on resuscitationscienceandprovidethemostuptodateevidence-based guidelines for by laypersons, healthcare providers and those responsibleforhealthpolicyacrossEurope.
InternationalLiaisonCommitteeonResuscitation
ILCORexiststosavemorelivesgloballythroughresuscitation.19,20 This vision is pursued through promoting, disseminating and advocating for international implementation of evidence-informed resuscitationandfirstaid,usingtransparentevaluationandconsen- sussummaryofscientificdata.TheERC asone ofthefounding membersofILCORandcontinues toworkcloselywith ILCORin pursuitofthosegoals.
AkeyactivityofILCORisthesystematicassessmentofevidenceto produceinternationalconsensusonsciencewithtreatmentrecommen- dations. Produced initially every 5 years, ILCOR transitioned to a continuousevidenceevaluationin2017.The2020CoSTR waspublished inOctober2020andcomprises184structuredreviewsofresuscitation science21!29whichinformtheERCGuidelinespresentedhere.
Guidelinedevelopmentprocess
Healthcare systems rely increasingly on high-quality, evidence- informed clinical practice guidelines. As the influence of such guidelines has grown and the rigour of the evidence evaluation processinformingthecontentofguidelineshasincreased,attention hasturnedtoraisingthestandardsandtransparencyfortheguideline developmentprocess.30
TheInstituteofMedicineestablishedqualitystandardsforclinical practice guidelines in 2011,31 shortly followed bythe Guidelines InternationalNetwork.32TheERCGuidelinesfollowedtheprinciples forguidelinedevelopmentdevelopedbytheGuidelinesInternational Network.32Thisincludesguidanceonpanelcomposition,decision- makingprocess, conflictsofinterest,guidelineobjective, develop- mentmethods,evidencereview,basisofrecommendations,ratingsof evidenceandrecommendations,guidelinereview,updatingprocess- es, and funding. A written protocol describing the guideline development process was developed and approved by theERC Boardbeforethestartoftheguidelinedevelopmentprocess.
CompositionofGuidelineDevelopmentGroup
TheERCArticlesofIncorporationandBylaws(https://erc.edu/about) setouttheformalprocessbywhichtheERCappointsitsGuideline
DevelopmentCommittees.TheDirectorofGuidelinesandILCORis electedbytheGeneralAssemblyoftheERCandmandatedtoco- ordinatetheguidelineprocess.TheyweresupportedbyaGuideline DevelopmentCommitteecomprising:DirectorGuidelinesandILCOR (Chair),Co-chairScienceforthefourstandingcommittees(BLS/AED;
ALS;PLS;NLS),Othermembers(DirectorofTraining,Directorof Science,ERCViceChair,ERCChair,Editor-in-ChiefResuscitation, Writinggroupchairs)andERCstaff.
TheERCBoardidentifiedthetopicsincludedintheERCGuidelines andappointedthe writinggroupchairs andmembers. Followinga reviewofconflictsofinterest(asdescribedbelow)writinggroupchairs andmemberswereappointedbytheBoard.Memberswereappointed based on their credibility as leading (or emerging) resuscitation scientists/clinicians/methodologists and to ensure a balance of professions(medicine,nursing,paramedicine),earlycareermembers, gender and ethnicity, geographical balance across Europe and representatives of key stakeholder organisations. The appointed writing groups rangedin sizefrom 12!15 members. Mostwriting group members were physicians (88%), who worked alongside clinicians froma nursing,physiotherapy and occupational therapy backgroundsaswellasresearchscientists.Aquarterofthewriting groupmemberswerefemale,and15%wereearlyintheircareers.The writing groupscame from25countriesincludingAustria,Belgium, Croatia, Cyprus, Czech Republic, Denmark, France, Germany, Greece,Holland,Iceland,Ireland,Italy,Netherlands,Norway,Poland, Romania,Russia,Serbia,Spain,Sudan,Sweden,Switzerland,United StatesofAmericaandUnitedKingdom.
Theroledescriptionforwritinggroupmemberscomprised:
" Provideclinicalandscientificexpertisetotheguidelinewriting group.
" Actively participate in the majority of guideline writing group conferencecalls.
" Systematicallyreviewthepublishedliteratureonspecifictopicsat therequestoftheguidelinewritinggroup.
" Presentreviewfindingsandleaddiscussionswithinthegroupon specifictopics.
" Developandrefineclinicalpracticealgorithmsandguidelines.
" Fulfil the International Committee of Medical Journal Editors (ICMJE)requirementsforauthorship.
" Bepreparedtobepubliclyaccountableforthecontentsofthe guidelinesandpromotetheiradoption.
" ComplywiththeERCconflictofinterestpolicy.
Decisionmakingprocesses
TheERCguidelinesarebasedontheILCORCoSTRs.21!29Where treatmentrecommendationsareprovidedbyILCOR,thesehavebeen adopted by the ERC. In areas where no relevant treatment recommendationexistedthemethodusedtoarriveatrecommenda- tionswasbasedonreviewanddiscussionoftheevidencebythe workinggroupuntilconsensuswasachieved.Thewritinggroupchairs ensuredthateachindividualontheworkinggrouphadtheopportunity topresentanddebatetheirviewsandensuredthatdiscussionswere openandconstructive.Allmembersofthegroupneededtoagreeto endorse anyrecommendations.Anyfailuretoreachconsensusis madeclearinthefinalwordingoftherecommendation.Thequorum forconductingwritinggroupbusinessandreachingconsensuswillbe atleast75%ofthewritinggroup.
Theguidelinescopeandfinalguidelineswerepresentedtoand approvedbytheERCGeneralAssembly.
Please citethisarticlein pressas: G.D.Perkins,etal., European ResuscitationCouncilGuidelines2021: Executivesummary,
Conflictofinterest
Conflictofinterest(COI)wasmanagedaccordingtotheERCpolicyfor COI(seesupplementalmaterial).Writinggroupmemberscompleted anannualCOIdeclaration.TheCOIdeclarationwasreviewedbythe GovernanceCommitteeandareportpreparedfortheERCBoard.
Writinggroupmemberconflictswerepostedon theERCwebsite throughtheguidelinedevelopmentprocess.33
Thewritinggroupchairandatleast50%ofthewritinggroupwere requiredtobefreeofcommercialconflictsofinterest.Atthechair's discretion, writing group members with a COI were still able to participateindiscussionsthatrelatetothistopic,butwerenotinvolved indraftingorapprovingrecommendation.
TheERChasfinancialrelationshipswithbusinesspartnerswho supporttheoverallworkoftheERC.34ThedevelopmentoftheERC guidelinesoccurentirelyindependentlyfromtheinfluenceofbusiness partners.
Scopeofguidelines
TheERC guidelinesprovide guidance through itsnetwork of 33 national resuscitation councils. The intended audience are lay- persons,firstaiders,firstresponders, communityhealthcarestaff, ambulancestaff,hospitalstaff,trainersandinstructors,andthose responsibleforhealthcarepolicyandpractice. Theguidelinesare relevantforuseinboththecommunity(out-of-hospital)andhospital (in-hospital)settings.Thescopeofindividualguidelinesectionswas developedbythewritinggroupsatthestartof2019.Theguideline scopeswerepostedforpublicconsultationfor2weeksinMay2019 priortobeingfinalisedandapprovedbytheERCGeneralAssemblyin June2019.
TheGuidelinescoverthefollowingtopics
" Epidemiology35
" Systemssavinglives36
" Adultbasiclifesupport37
" Adultadvancedlifesupport38
" Specialcircumstances39
" Postresuscitationcare(incollaborationwiththeEuropeanSociety ofIntensiveCareMedicine)40
" FirstAid41
" Neonatallifesupport42
" Paediatriclifesupport43
" Ethics44
" Education45
Methods
Thestep-by-stepprocessforguidelinedevelopmentissummarisedin Fig.1.InbrieftheERCBoarddefinedthetopicareasthatwouldbe coveredin the guidelinesand appointedthe writinggroups. The writinggroupsdevelopedthescopeusingastandardisedtemplate.
Thescopecontainedtheoverallobjective,intendedaudience,setting fortheiruseandthekeytopicsthatwouldbecovered.Theguideline scopes were presented for public comment, revised, and then approvedasdescribedintheprevioussection.Writinggroupsthen proceededtoidentifyandsynthesise therelevantevidencewhich werethensummarisedandpresentedastheguidelinerecommen- dations.Thedraftguidelinesunderwentafurtherperiodofpublic consultation before peer review and approval by the General Assembly.
Evidencereviews
TheERCGuidelinesareinformedbytheILCOREvidenceEvaluation processwhichisdescribedindetailelsewhere.23Insummary,ILCOR has undertaken three styles of evidence evaluation since 2015 comprising systematic reviews, scoping reviews and evidence updates.
The ILCOR systematic reviews follow the methodological principlesdescribedbytheInstituteofMedicine,CochraneCollabo- ration,andGradingofRecommendationsAssessment,Development, andEvaluation(GRADE).46Thereviewsarepresentedaccordingto thePreferredReportingItemsforaSystematicReviewandMeta- Analysis(PRISMA)(Table1).47
ILCOR systematic reviews were supplemented by scoping reviews,undertakeneitherdirectlybyILCORorbymembersofthe ERCwritinggroups.Unlikesystematicreviews(whichtendtohavea focused/narrowquestion),scopingreviewstakeabroaderapproach toatopicandseektoexamineandmaptheextent,rangeandnatureof research activity.23 This enabled theguideline group to produce narrativesummariesacrossabroaderrangeofsubjectsthanwouldbe possible through solely conducting systematic reviews. Scoping reviewsfollowedtheframeworkoutlinedbyILCORandwerereported in accordancewith thePRISMAextension forscoping reviews.48 Unlikesystematicreviews,neithertheILCORnortheERCscoping reviewscouldleadtoaformalCoSTR.
ThefinalmethodofevidenceevaluationusedbyILCORwere evidenceupdates.23Theseweredesignedtoaddresstopicsthathad notbeenformallyreviewedforseveralyears,inordertoidentifyifany newevidencehademergedtothatshouldpromptaformalreview.
Evidenceupdateseitherprovidedassurancethatprevioustreatment recommendationsremainedvalidorhighlightedtheneedtoupdatea previoussystematicreview.Inthemselves,evidenceupdatesdidnot leadtoanychangestoCoSTR.
Fig.1–Step-wiseprocessfordevelopmentoftheERC guidelines.
Please citethisarticlein pressas: G.D.Perkins,etal., European ResuscitationCouncilGuidelines2021: Executivesummary,
Systematic reviews from other organisations were eligible for inclusioniftheywereconductedandreportedaccordingtoAMSTAR (Assessingthemethodologicalqualityofsystematicreviews)49and PRISMA47recommendations,areinthepublicdomainandhavebeen peerreviewed.
Wheretopicsofinterestfelloutsidetheremitofevidencereviewed byILCOR,ERCwritinggroupsundertookscopingreviewstomapthe availableevidenceandsynthesiskeyinformationandthemes,using thesameapproachundertakenbyILCOR.
Guidelinerecommendations
Conciseguidelinesforclinicalpractice
MostERCguidelineswillbeusedin emergencieswhereefficient, timelyactioniscritical.Theconciseguidelinesforclinicalpractice sectionsareintendedtoprovideclear,succinct recommendations with easily understood algorithms to provide the reader with unambiguous,stepbystepinstructions.Assuch,thesecomponents oftheguidelinesdonotincludeinformationaboutthelevelofevidence orstrengthofrecommendations.Instead,thisinformationispresented intheevidenceinformingtheguidelinessections.
Evidenceinformingtheguidelines
Formal ERC treatment recommendations are limited to those informedbyILCORCoSTR.TheILCORCoSTRsareconstructed followingarigorousevidenceevaluationinformedbyGRADE.The detailed steps are described in the ILCOR Evidence Evaluation ProcessSummary.Inbriefthesetreatmentrecommendationsprovide a summary of the certainty of evidence and a strength of recommendation. Thecertainty (quality)of evidenceranges from verylowtohigh(seeTable2).
ThestrengthofrecommendationsfromILCORreflecttheextentto whichthetaskforcewasconfidentthatthedesirableeffectsofan action or intervention outweighed the undesirable effects. Such deliberationswereinformedbytheEvidencetoDecisionFramework developedbyGRADEwhichenablesconsiderationofthedesirable effects,undesirableeffects,certaintyofevidence,values,balanceof effects, resources required, certainty of evidence of required
resources, cost effectiveness,equity, acceptability and feasibility.
There were two main strengths of recommendation ! a strong recommendation indicates thatthe task forcewas confidentthat desirableeffects outweightheundesirableeffects.Strong recom- mendations typically use terms such as ‘we recommend’. Weak recommendations(wherethetaskforcewasnotconfidentthatthe desirableeffectsoutweightheundesirableeffects)typicallyusethe term‘wesuggest’.
There aremany areasofresuscitationsciencewherethereis eithernoevidenceorinsufficientevidencetoinformanevidence- based treatment recommendation. When this occurs the expert opinion of the writinggroup is presented. The guidelines clearly document which aspects of the guidelineare evidence informed versusexpertconsensus.
Stakeholderconsultationandpeerreview
DraftsoftheERCGuidelineswerepostedontheERCwebsitefor publiccommentbetween21stOctober2020and5thNovember2020.
Theopportunitytocommentontheguidelineswasadvertisedthrough Table1–Summaryoutlineoftheprocessstepsforthe2020CoSTRSysRevs(reproducedfrom23).
Taskforcesselect,prioritise,andrefinequestions(usingPICOSTformat) Taskforcesallocatelevelofimportancetoindividualoutcomes TaskforcesallocatePICOSTquestiontoSysRevteam*
SysRevregisteredwithPROSPERO
SysRevteamworkswithinformationspecialiststodevelopandfine-tunedatabase-specificsearchstrategies Revisedsearchstrategiesusedtosearchdatabases
ArticlesidentifiedbythesearcharescreenedbyallocatedmembersoftheSysRevteamusinginclusionandexclusioncriteria SysRevteamagreesonfinallistofstudiestoinclude
SysRevteamagreesonassessmentofbiasforindividualstudies GRADEEvidenceProfiletablecreated
DraftCoSTRscreatedbySysRevteam
Evidence-to-decisionframeworkcompletedbytaskforce PublicinvitedtocommentondraftCoSTRs
DetailediterativereviewofCoSTRstocreatefinalversion PeerreviewoffinalCoSTRdocument
Footnote:CoSTRindicatesConsensusonCardiopulmonaryResuscitationandEmergencyCardiovascularCareScienceWithTreatmentRecommendations;
GRADE,GradingofRecommendationsAssessment,Development,andEvaluation;PICOST,population,intervention,comparison,outcome,studydesign,time frame;PROSPERO,InternationalProspectiveRegisterofSystematicReviews;andSysRev,systematicreview.*Systematicreviewteamcouldbeknowledge synthesisunit,expertsystematicreviewer,ortask-force-ledteaminvolvingcontentexpertsfromtheILCORtaskforce(s),anddelegatedmemberoftheContinuous EvidenceEvaluationWorkingGroupandScientificAdvisoryCommittee.
Table2–Certainty(quality)ofevidenceforaspecific outcome(oracrossoutcomes).
GRADE certaintylevel
Description
High Weareveryconfidentthatthetrueeffectlies closetothatoftheestimateoftheeffect Moderate Wearemoderatelyconfidentintheeffect
estimate:Thetrueeffectislikelytobecloseto theestimateoftheeffect,butthereisa possibilitythatitissubstantiallydifferent Low Ourconfidenceintheeffectestimateislimited:
Thetrueeffectmaybesubstantiallydifferent fromtheestimateoftheeffect
Verylow Wehaveverylittleconfidenceintheeffect estimate:Thetrueeffectislikelytobe substantiallydifferentfromtheestimateofeffect
Please citethisarticlein pressas: G.D.Perkins,etal., European ResuscitationCouncilGuidelines2021: Executivesummary,
