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ILCOR – 2023 Resuscitation Science Evidence Review

January 3, 2024

Written by Samuel Rouleau

Spoon Feed
The International Liaison Committee on Resuscitation (ILCOR) released updates on a broad range of resuscitation practices. Check out this JournalFeed to stay up to date!

It’s our job to be experts at resuscitation!
The ILCOR 2023 update is insightful, yet it’s lengthy and covers a myriad of topics. I have summarized the most salient points that are applicable to the Emergency Department. See the full guidelines for recommendations on drowning and neuroprognostication. I have included my opinion in italics.

Calcium during Cardiac Arrest

  • Do not routinely use calcium for out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA).
  • The COCA trial was stopped early due to a concern for calcium administration in OHCA being associated with lower likelihood of attaining ROSC and worse neurologic outcome.
  • Calcium should be given early if you have a suspicion it will address the underlying etiology (hyperkalemia, wide QRS, calcium channel blocker overdose, etc). However, giving calcium 15 minutes into CPR just because you’re emptying out the code cart is not indicated and may cause harm.

Double Sequential External Defibrillation

  • For adults undergoing CPR, if the rhythm is ventricular fibrillation or pulseless ventricular tachycardia after 3 or more consecutive shocks, then double sequential external defibrillation (DSED) should be considered. DSED should be performed by a single operator performing defibrillation in sequence.
  • There is not enough evidence to recommend vector change defibrillation at this time.
  • This update is based on one trial that found that patients with refractory ventricular fibrillation had better neurologic outcome and survival to hospital discharge than standard defibrillation.
  • In patients with refractory ventricular fibrillation, consider reducing or completely stopping epinephrine administration, as epinephrine can be arrhythmogenic.

Neonatal Resuscitation

  • Need a 5-minute NRP refresher? See the JournalFeed version! Palpation is not reliable in determining neonatal heart rate. Electrocardiography is the most preferred method. Pulse oximetry and auscultation are alternatives if electrocardiography is not available, but both have significant limitations.
  • Knowing the heart rate of a neonate is essential to following the neonatal resuscitation guidelines; place the neonate on the heart rate monitor expeditiously.
  • There is no evidence to suggest a benefit end-tidal CO2 monitoring for non-invasive ventilation methods during neonatal resuscitation.
  • Positive-pressure ventilation with low-concentration oxygen should have been employed prior to starting chest compressions. Once chest compressions have started, then increase the supplemental oxygenation concentration.
  • The 2-thumb encircling technique of delivering compressions is preferred over the 2-finger technique.
  • For neonates, the recommended compression-to-ventilation ratio for CPR is 3:1.


  • The evidence is poor for routine use of ECPR in adults, though it can be considered in certain settings.
  • For pediatric patients who suffer IHCA, ECPR should be considered based on pediatric specific data from 4 observational studies.
  • Specific situations when you may want to consider ECPR for patients of all ages: severe hypothermia, toxicologic etiology of cardiac arrest, pulmonary embolism, recurrent ventricular fibrillation. The earlier the patient gets on the circuit, the more likely they are to have a better outcome.

How will this change my practice?
Resuscitation science is one of my passions. When patients have a pulse, we are diligent about medication selection and administration. During CPR, many of us may give a medication (i.e. magnesium, sodium bicarbonate, or calcium) as the code goes on “just to try” something. Medication administration during CPR should be based on your clinical assessment; know what you are intending to treat and treat it quickly. Stay current on resuscitation guidelines!

Another Spoonful

  • Nearly simultaneous shocks in an orthogonal arrangement may be most effective for defibrillation (and to avoid frying your defibrillator), according to this animal study.
  • If you’re going to use DSED, don’t wait too long – earlier may be better.
  • DSED seemed to edge out vector change (A-P vs usual pad placement) for defibrillation of refractory cases and was definitely better than standard defib in this RCT.
  • This has nothing to do with dual defib, but the optimal defib dose in children may be closer to 2J/kg rather than 4J/kg.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2023 Nov 9. doi: 10.1161/CIR.0000000000001179. Online ahead of print.