Cardiac arrest and advanced life support

Sudden cessation of mechanical activity. Cardiac arrest is the sudden cessation of effective cardiac mechanical activity. Survival with good neurology depends on a few things done well and without delay: immediate high-quality chest compressions, rapid defibrillation of a shockable rhythm, reversal of the cause, and high-quality post-resuscitation care. The algorithm is universal and rehearsed for execution under stress, including regional variations and the evidence behind each drug. [1]

The chain of survival and high-quality CPR

The chain of survival — early recognition and call for help, early high-quality cardiopulmonary resuscitation, early defibrillation, and high-quality post-resuscitation care — frames the whole effort, and the two pre-hospital links (CPR and defibrillation) are the ones that determine good survival. The quality of the CPR is decisive. The compressions are delivered at a rate of 100 to 120 per minute, to a depth of 5 to 6 centimetres in the adult, with full chest recoil between compressions and minimal interruption (pauses kept below 5 seconds and confined to the rhythm check and the shock). The compressor is rotated every two minutes to prevent fatigue, and excessive ventilation is avoided because it raises intrathoracic pressure and reduces coronary and cerebral perfusion. The compression-to-ventilation ratio for the adult with an unprotected airway is 30 to 2; once the airway is secured with a cuffed tracheal tube, compressions continue uninterrupted at 100 to 120 per minute with around 10 breaths per minute. High-quality CPR is the foundation on which everything else is built, and no intervention should be allowed to compromise it.[1]

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1. [1]Drennan IR, Berg KM, Böttiger BW, et al. Advanced Life Support: 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations Resuscitation, 2025.PMID 41117578
2. [2]Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest N Engl J Med, 2021.PMID 34133859
3. [3]Kudenchuk PJ, Daya M, Dorian P, et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest N Engl J Med, 2016.PMID 27043165
4. [4]Ji C, Pocock H, Deakin CD, et al. Adrenaline for traumatic cardiac arrest: A post hoc analysis of the PARAMEDIC2 trial Resusc Plus, 2025.PMID 40026713
5. [5]Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest N Engl J Med, 2018.PMID 30021076
6. [6]Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest N Engl J Med, 2013.PMID 24237006
7. [7]Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med, 2002.PMID 11856793