Out-of-Hospital Cardiac Arrest Management

Primary Recommendation

The American Heart Association recommends that for witnessed shockable out-of-hospital cardiac arrest, paramedics should focus on minimally interrupted chest compressions with basic airway management and delay endotracheal intubation until after initial CPR and defibrillation attempts fail or ROSC is achieved (Class IIb, LOE C) 1, 2, 3
Delayed endotracheal intubation combined with passive oxygen delivery and minimally interrupted chest compressions was associated with improved neurologically intact survival after out-of-hospital cardiac arrest in patients with adult witnessed VF/pulseless VT 1, 2, 3

The 2015 International Consensus found that bundles of care involving minimally interrupted cardiac resuscitation showed significant benefit, with an OR of 3.6 (95% CI, 1.77–7.35) for survival with favorable neurologic outcome 4
The International Consensus suggests that where EMS systems have adopted bundles of care involving minimally interrupted cardiac resuscitation, the bundle is a reasonable alternative to conventional CPR for witnessed shockable out-of-hospital cardiac arrest (weak recommendation, very-low-quality evidence) 4, 5

Supraglottic airways are reasonable alternatives to endotracheal intubation during CPR performed by trained providers, as they can be inserted without interrupting chest compressions 1, 2, 3
Advanced airway placement may be considered after initial CPR and defibrillation attempts fail 1, 2, 3

Interruptions of chest compressions must be limited to less than 10 seconds for laryngoscopy and tube passage through the vocal cords 6, 7, 8
The intubating provider must be fully prepared with laryngoscope blade and tube ready before compressions are paused 6, 7, 8

Supraglottic airways are reasonable alternatives to both bag-mask ventilation (Class IIa, LOE B) and endotracheal intubation (Class IIa, LOE A) during CPR performed by trained providers 9
Supraglottic airways can be inserted without interrupting chest compressions, have easier initial training and skill maintenance, and do not require direct visualization 3, 1, 2, 9, 10

Continuous waveform capnography is recommended as the most reliable method of confirming and monitoring correct placement of endotracheal tubes (Class I, LOE A) 6, 7, 8, 9
Waveform capnography has demonstrated 100% sensitivity and 100% specificity for identifying correct endotracheal tube placement in cardiac arrest victims 6, 7, 8

Approximately two‑thirds of victims who receive rescue breathing during cardiac arrest vomit, and about 86 % of those who require combined compressions and ventilations experience vomiting【11】.

When vomiting is observed, briefly pause chest compressions, turn the patient onto their side (log‑roll if a cervical spine injury is suspected), and clear the airway with a finger sweep, cloth, or suction device before resuming compressions【11】.
The pause for airway clearance should be kept under 10 seconds to minimize interruption of perfusion【12】.

The 2020 American Heart Association (AHA) Guidelines assign a Class I recommendation with Level of Evidence C‑LD to keep total pauses in chest compressions as short as possible【13】.
All interruptions, including those for vomiting, should be limited to less than 10 seconds whenever feasible【13】【14】.
The target chest‑compression fraction during resuscitation should be ≥ 60 % (compressions occupy at least 60 % of total resuscitation time)【13】.

For patients without an advanced airway, it is reasonable to pause compressions for fewer than 10 seconds to deliver two rescue breaths【14】【15】.

Do not use abdominal thrusts or the Heimlich maneuver to clear vomitus during CPR, as they are unnecessary and may cause injury【11】.
Do not perform prolonged airway‑clearance techniques that extend the interruption beyond what is essential【13】.
Do not check for a pulse or cardiac rhythm while managing vomiting; focus solely on airway clearance and rapid resumption of compressions【13】【16】.
Do not apply rigid spinal‑immobilization devices if a spinal injury is suspected; instead, use manual cervical stabilization while turning the patient【13】【15】.

Preshock pauses longer than 10 seconds are associated with reduced survival to hospital discharge; each additional 5‑second pause increases the odds of death (OR 1.86, 95 % CI 1.10‑3.15)【12】.

Assign one rescuer to manage airway clearance while another remains ready to restart compressions immediately, ensuring no delay in perfusion【13】.
Rotate the person performing chest compressions at least every 2 minutes to prevent fatigue‑related decline in compression quality, as recommended by the AHA Guidelines【13】【16】.

The American Heart Association recommends beginning resuscitation with bag‑mask ventilation using a 30:2 compression‑to‑ventilation ratio before placing any advanced airway device. 17, 18

Intubation should be performed when the rescuer is unable to provide adequate ventilation with a bag‑mask on an unconscious patient. 19
Intubation is also indicated when the patient lacks airway‑protective reflexes and requires a definitive airway. 19

Laryngoscopy and tube passage must be completed in ≤ 10 seconds to minimise interruptions in chest compressions (Class IIb, LOE C). 19
The intubator must have the laryngoscope blade and endotracheal tube prepared and ready before any pause in compressions. 19
Chest compressions should resume immediately after the tube passes through the vocal cords. 19
If the first intubation attempt fails, clinicians should switch to a supraglottic airway rather than repeat attempts, to avoid prolonged pauses. 19

Supraglottic airways can be inserted without any interruption of chest compressions, providing a rapid advanced airway when intubation is not feasible. 19

After securing an advanced airway, deliver 10 breaths per minute (one breath every 6 seconds) while maintaining continuous, uninterrupted chest compressions. 17

Continuous waveform capnography is the most reliable method for confirming correct tube placement (Class I, LOE A). 19
Waveform capnography shows 100 % sensitivity and 100 % specificity for detecting correct tube placement in cardiac arrest victims. 19
When waveform capnography is unavailable, a colorimetric CO₂ detector combined with clinical assessment is recommended (Class IIa, LOE B). 19