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Spoon Feed – 2020 AHA CPR and Advanced Life Support Guidelines

December 28, 2020

Written by Clay Smith

Spoon Feed
The are some substantive changes in AHA resuscitation guidelines you need to know about. Here is the Spoon Feed!

Why does this matter?
The last major AHA resuscitation guideline update was in 2015. This is an executive summary of the changes from then to now for adults, children, and neonates. And if you want some research ideas, each section lists a host of knowledge gaps that remain. We still have much to learn. Just 12% of the evidence for what we do comes from multiple RCTs or at least one RCT (i.e. Level A or B evidence).

You, call 911. You, bring me an AED.
We will run through the executive summary of adult and pediatric guidelines and go into detail over the next two days.


  • CPR – high quality is emphasized.

  • IV route is preferred over IO. See JF point and counterpoint posts on this.

  • Double sequential defibrillation is allowed, but more evidence is needed. See our coverage of the DOSE VF RCT.

  • Early dosing of epinephrine appears to improve survival, especially in those with non-shockable rhythm.

  • Opioid overdose is emphasized as a cause of respiratory arrest. Lay rescuer use of naloxone is emphasized. If full arrest, just do the usual.

  • Pregnant patients with arrest – a decision should be made to do perimortem c-section within 5 minutes of arrest.

  • They recommend against using POCUS for prognostication in arrest.

  • There is an emphasis on post-arrest care – BP, SpO2, temperature management, seizure control, etc.

  • These guidelines focus heavily on improving neuroprognostication, using a multimodal approach.

  • Finally, they add Recovery as the 6th link in the chain of survival and emphasize the importance of setting expectations with family and the need for rehabilitative services for survivors.


  • Respiratory rate targets should be 20-30 per minute instead of 10-12. JF suggested this last year.

  • Use of cuffed endotracheal tubes is encouraged.

  • Cricoid pressure is out.

  • Early epinephrine is in, just as in adults above, especially in non-shockable rhythm.

  • Using diastolic BP to guide CPR if an invasive line is already in is a good idea. JF covered this two years ago.

  • Use EEG to detect and treat subclinical seizure activity post-arrest.

  • There is a similar focus on recovery after arrest, getting rehab, and setting realistic expectations.

  • For septic shock, boluses of 10-20mL/kg with frequent reassessments are recommended; balanced fluids are mentioned as an option (yes!). Norepinephrine or epinephrine may be used in refractory hypotension.

  • The fact that children are impacted by the opioid epidemic is emphasized – some as accidental ingestion, some intentional. IM or intranasal naloxone should be given if altered with respiratory depression.

Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S337-S357. doi: 10.1161/CIR.0000000000000918. Epub 2020 Oct 21.

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