Jisook Lee, Do Kyun Kim, Jin-Tae Kim, Jae Yoon Na, Bobae Park, Soo In Jeong, June Dong Park, Sung Phil Chung, Tae-Youn Kim, Youdong Sohn, Gyuhong Shim, Young Hwa Jung, Yunhee Oh, Chun Song Youn, Mi Jin Lee, Chang Hee Lee, Youngbin Jang, Yong Soo Jang, Gyu Chong Cho, Kyoung-Chul Cha, Ju Sun Heo, Sung Oh Hwang, Steering Committee for the 2025 Korean Guidelines for Cardiopulmonary Resuscitation
Received March 26, 2026 Accepted March 29, 2026 Published online June 5, 2026
Pediatric cardiac arrest primarily arises from asphyxia in infants and trauma in older children, contrasting with adult etiologies dominated by cardiac events. This underscores prevention as the cornerstone of pediatric basic life support, through injury mitigation like child restraint systems and water supervision, safe sleep practices including supine positioning on firm surfaces with caregiver smoking cessation to reduce sudden infant death syndrome, plus awareness of child abuse and adolescent suicide prevention. In hospitals, pediatric early warning systems (PEWS) enable early deterioration detection via vital sign scoring for timely intervention. Major updates in the 2025 pediatric basic life support guidelines reflect evidence-driven refinements. First, hospitals should implement PEWS to prompt rapid response teams for at-risk inpatients. Second, all rescuers (lay and healthcare providers) should employ the two-thumb encircling hands technique for infant chest compressions for optimal depth (about 4 cm), rate (100–120 beats per minute), and recoil; one-hand heel compression serves as backup if infeasible. Third, lay rescuers may apply automated external defibrillators for nontraumatic out-of-hospital cardiac arrest in children aged 1 year or older, prioritizing prompt attachment after initial cardiopulmonary resuscitation (CPR) cycles to address potential shockable rhythms. Fourth, for infant foreign body airway obstruction, alternate five back blows (over the spine between scapulae) with five chest thrusts (using heel-of-hand on sternum) until cleared or unresponsive, then transition to CPR. These updates aim to enhance bystander intervention, CPR quality, and survival with favorable neurologic outcomes in pediatric cardiac arrest.
Do Kyun Kim, Jin-Tae Kim, Jae Yoon Na, Bobae Park, Jisook Lee, Soo In Jeong, June Dong Park, Sung Phil Chung, Tae-Youn Kim, Youdong Sohn, Gyuhong Shim, Young Hwa Jung, Yunhee Oh, Chun Song Youn, Mi Jin Lee, Chang Hee Lee, Youngbin Jang, Yong Soo Jang, Gyu Chong Cho, Kyoung-Chul Cha, Ju Sun Heo, Sung Oh Hwang, Steering Committee for the 2025 Korean Guidelines for Cardiopulmonary Resuscitation
Received March 5, 2026 Accepted March 9, 2026 Published online June 5, 2026
The 2025 Korean pediatric advanced life support guideline update introduces clinically important revisions emphasizing airway strategy, physiologic resuscitation targets, post–cardiac arrest hemodynamics, neuroprotection, and extracorporeal support. In out-of-hospital pediatric cardiac arrest, bag-mask ventilation is now suggested over endotracheal intubation or supraglottic airway placement. In in-hospital arrest, evidence is insufficient to favor bag-mask ventilation versus advanced airways; however, endotracheal intubation or supraglottic airway insertion is reasonable when performed with minimal interruption or when bag-mask ventilation is ineffective. For patients with an advanced airway in place, age-adjusted ventilation rates are proposed to avoid hypoventilation and hyperventilation: 30 breaths per minute (<1 yr), 20–30 breaths per minute (1–8 yr), and 10–20 breaths per minute (8–18 yr in healthcare settings). When invasive arterial monitoring is available during in-hospital cardiac arrest, target diastolic blood pressure is ≥25 mmHg in infants and ≥30 mmHg in children ≥1 year. After return of spontaneous circulation, systolic blood pressure during the first 6 hours should be maintained above the age-specific 10th percentile. Neuroprognostication should be multimodal, incorporating serial examinations, electroencephalography (up to 72 hours), early computed tomography (<24 hours), magnetic resonance imaging (72 hours to 2 weeks), lactate trends, and pupillary reflexes. Extracorporeal cardiopulmonary resuscitation (CPR) is limited to appropriately resourced hospitals and may be considered for selected in-hospital arrests (e.g., cardiac disease) unresponsive to conventional CPR; evidence remains insufficient for out-of-hospital use. These revisions shift pediatric resuscitation toward physiology-guided, resource-stratified, and neuroprotective care.
Hyo Jin Bang, Chun Song Youn, Min Chul Kim, Yongwhan Lim, Young-Jae Cho, Bitna Chu, June-Sung Kim, Youn-Jung Kim, Byoung-Gil Yoon, Jin Park, Min-Ju Kang, Kyung Woon Jeung, Soo Hyun Kim, Je Hyeok Oh, Taegyun Kim, Sang Hoon Oh, Yong Soo Kim, Changshin Kang, Dong Hun Lee, Jin Hong Min, Hyo Joon Kim, Do Kyun Kim, Tae-Yun Kim, Yudong Sohn, Gyuhong Shim, Young Hwa Jung, Yunhee Oh, Mi Jin Lee, Jisook Lee, Chang Hee Lee, Young Bin Jang, Yong Soo Jang, Gyu Chong Cho, Kyoung-Chul Cha, Ju Sun Heo, Sung Oh Hwang, Sung Phil Chung
Received February 15, 2026 Accepted February 25, 2026 Published online June 4, 2026
This guideline summarizes evidence-based post–cardiac arrest care following the return of spontaneous circulation (ROSC) in adults, incorporating updates from the 2025 Korean Guidelines for Cardiopulmonary Resuscitation and contemporary international evidence. Recommendations were informed by recent randomized controlled trials and systematic reviews, with an emphasis on patient-centered outcomes and practical clinical applications. After ROSC, early evaluation should focus on identifying reversible causes. A 12-lead electrocardiogram should be obtained promptly, with echocardiography and whole-body computed tomography performed when clinically indicated to assess cardiac function and detect noncardiac or occult etiologies. Respiratory management aims to minimize secondary brain injury by preventing hypoxemia and hyperoxemia. Highly inspired oxygen concentrations may be used initially, followed by titration to an appropriate oxygen saturation level once reliable measurements are available, and ventilation should target normocapnia. Hemodynamic management prioritizes adequate organ perfusion and prompt treatment of shock, including active correction of hypotension. Routine immediate coronary angiography is not recommended in patients without ST-segment elevation. However, urgent angiography is indicated in those with ST-segment elevation, cardiogenic shock, or a high likelihood of ongoing myocardial ischemia. In comatose survivors, temperature control is essential. The selected target temperature should be maintained for at least 24 hours, with active fever prevention for 36 to 72 hours. Additional intensive care unit management includes glucose control and seizure monitoring. Routine prophylactic antibiotics or anticonvulsants are not recommended. Neuroprognostication should use a multimodal approach after confounders, such as sedation and temperature management, are addressed, integrating clinical examination, electrophysiology, biomarkers, and neuroimaging to support individualized decision-making.
Tae-Youn Kim, Gyo Jin Ahn, Kyoung-Chul Cha, Dong-Hyeok Kim, Youdong Sohn, Young Song, Gyuhong Shim, Do Kyun Kim, Yunhee Oh, Jin Wi, Chun Song Youn, Myung-Lyeol Lee, Mi Jin Lee, Byung Kook Lee, Byung Heon Lee, Ji Sook Lee, Chang Hee Lee, Hannah Lee, Youngbin Jang, Yong Soo Jang, Young Hwa Jung, Woo Jin Jung, Sung Phil Chung, Gyu Chong Cho, Ju Sun Heo, Sung Oh Hwang
Received February 14, 2026 Accepted February 20, 2026 Published online June 4, 2026
The 2025 update of the Korean guidelines for cardiac arrest under special circumstances incorporates new evidence and expert consensus to clarify when clinicians should modify standard resuscitation algorithms. For cardiac arrest caused by acute hyperkalemia, the guidelines suggest administering intravenous insulin with glucose; however, current evidence remains insufficient to recommend for or against routine use of sodium bicarbonate or calcium. In suspected pulmonary embolism–related cardiac arrest, thrombolytic therapy may be considered. In confirmed cases, thrombolysis, surgical embolectomy, or percutaneous mechanical thrombectomy may be appropriate, despite very low certainty of evidence. For opioid-related cardiac arrest, current evidence does not support the routine administration of naloxone in addition to standard advanced life support; however, naloxone may be administered when it is unclear whether the patient is in true cardiac arrest. The guidelines also emphasize managing cardiac arrest in the prone position. If the patient is intubated and immediate repositioning is unsafe or impractical, prone cardiopulmonary resuscitation and defibrillation may be attempted using invasive arterial pressure or end-tidal carbon dioxide monitoring to guide the timing of repositioning. Immediate supination is strongly recommended for non-intubated patients. Additional updates address drowning, severe hypothermia, pregnancy, anaphylaxis, and cardiac arrest during interventional procedures, underscoring the importance of early correction of reversible causes, appropriate airway strategies, and timely consideration of extracorporeal life support in selected cases. Overall, the 2025 recommendations highlight cautious, etiology-directed interventions and explicitly grade recommendation strength and certainty to support context-sensitive clinical decision-making in high-risk and resource-variable settings.
Sung Oh Hwang, Kyoung-Chul Cha, Woo Jin Jung, Young-Il Roh, Gyo Jin Ahn, Do Kyun Kim, Tae-Youn Kim, Youdong Sohn, Gyuhong Shim, Young Hwa Jung, Yunhee Oh, Chun Song Youn, Mi Jin Lee, Jisook Lee, Chang Hee Lee, Youngbin Jang, Yong Soo Jang, Gyu Chong Cho, Ju Sun Heo, Sung Phil Chung
Received February 14, 2026 Accepted February 20, 2026 Published online May 29, 2026
In Korea, more than 30,000 out-of-hospital cardiac arrests (OHCAs) occur each year, and the survival rate remains below 10%. Because OHCA is difficult to predict and typically occurs outside medical facilities, effective management requires not only healthcare professionals but also laypersons, including bystanders and first responders. Survival depends on an uninterrupted and efficient sequence of time-critical actions: early recognition of cardiac arrest and activation of emergency services; prompt bystander cardiopulmonary resuscitation (CPR); use of an automated external defibrillator (AED) for shockable rhythms; on-scene and in-hospital advanced life support with comprehensive post–cardiac arrest care; and systematic assessment of neurologic and functional outcomes followed by rehabilitation and recovery. The chain of survival describes these essential steps required to maximize survival after cardiac arrest and comprises five links: (1) early recognition and call for help; (2) immediate bystander CPR; (3) early defibrillation with an AED; (4) advanced life support and post–cardiac arrest care; and (5) rehabilitation and recovery for survivors. Cardiac arrest survival environment represents a societal infrastructure that sustains and optimizes both medical and nonmedical factors across prevention, treatment, and rehabilitation to reduce mortality. Establishing such an environment requires each community to develop integrated medical systems for prevention, treatment, rehabilitation, and recovery, alongside nonmedical strategies, including public awareness initiatives, widespread CPR education and bystander participation, AED dissemination, and coordinated community responsiveness of the emergency medical system.
Sung Phil Chung, Do Kyun Kim, Tae-Youn Kim, Youdong Sohn, Gyuhong Shim, Young Hwa Jung, Yunhee Oh, Chun Song Youn, Mi Jin Lee, Jisook Lee, Chang Hee Lee, Youngbin Jang, Yong Soo Jang, Gyu Chong Cho, Kyoung-Chul Cha, Ju Sun Heo, Sung Oh Hwang
Received February 14, 2026 Accepted February 25, 2026 Published online May 21, 2026
In response to the expanding body of research on cardiopulmonary resuscitation (CPR) and updates from the International Liaison Committee on Resuscitation, the 2020 Korean CPR guidelines have been revised. This article presents the development process and summarizes the major updates in the 2025 Korean CPR guidelines. Seven task forces were established, with members nominated by professional societies involved in CPR. Each task force formulated key clinical questions and conducted systematic evidence reviews using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. The 2025 CPR guidelines were finalized on the basis of the reviewed evidence and consensus discussions. The major updates are as follows: (1) addition of rehabilitation and recovery to the chain of survival; (2) inclusion of guidance for dispatchers on the use of automated external defibrillators; (3) recommendation that trained rescuers provide rescue breaths in cases of drowning-related cardiac arrest; (4) suggestion of double sequential defibrillation or vector change for refractory ventricular fibrillation; (5) revision of the target temperature range for post-resuscitation temperature management from 32–36 to 33–37.5 °C; (6) recommendation of public access defibrillation for children aged ≥1 year; (7) suggestion to use supraglottic airway devices and video laryngoscopy in neonatal resuscitation; (8) recommendation for the use of feedback devices in CPR training; and (9) addition of a first aid section addressing cardiac arrest–related emergencies. These guidelines reflect the most current evidence, and their implementation and dissemination are expected to improve survival after cardiac arrest.
Objective Healthcare providers frequently spend excessive time identifying a pulse and have difficulties in precisely verifying its existence. Point-of-care carotid artery ultrasound has been suggested as a potential substitute technique for pulse checks. This study aimed to evaluate the effectiveness of manual pulse checks, 2D carotid ultrasonography (USG), and rapid increases in endtidal carbon dioxide (EtCO2) levels in determining the return of spontaneous circulation (ROSC) in patients who experienced a cardiac arrest in an emergency department (ED).
Methods The study was designed as a single-center, prospective, observational study. Non-traumatic adult patients in cardiopulmonary arrest who were brought to the ED were included. Upon identifying cardiac arrest, the following data were recorded: the initial arrest rhythm, ultrasonographic and manual pulse evaluations, EtCO2 levels, resuscitation period, and vital signs post-ROSC. Team leaders’ judgement used for adjudication of ROSC used as the reference standart.
Results The investigation included 88 patients with a total of 642 CPR cycles administered to who suffered cardiopulmonary arrest. AUC values of the USG, EtCO2 and manual pulse checks were 0.974, 0.802 and 0.862 (p<0.001, p<0.001, p<0.001, respectively). AUC comparisons of USG vs manual pulse check and EtCO2 were significantly different, while manual pulse checks vs EtCO2 had no significant difference (p=0.001, p<0.001, p=0.167, respectively). The sensitivity of bedside USG for detecting carotid pulse was found to be 93.8%, with a specificity of 100%.
Conclusion This study suggests that 2D carotid ultrasonography can be effectively utilized for detecting pulses in patients suffering cardiopulmonary arrest.
Background Rescuer posture, position, and patient height during chest compressions (CC) influence its efficacy and efficiency. No clear recommendations exist on these aspects. It is essential to systematize the existing knowledge, especially for nurses and healthcare providers involved in resuscitation.
Purpose: To conduct a systematic review about the impact of rescuer posture, position, and manikin/patient height on CC efficacy and efficiency.
Methods The study followed PRISMA guidelines and was registered on PROSPERO. Eligibility criteria included peer-reviewed articles or conference papers comparing different rescuer postures, positions, or manikin/patient heights during CC performed with both hands, regarding efficacy or efficiency. Databases consulted: MEDLINE Complete, SPORTDiscus, Cochrane Reviews, and CINAHL Complete. Methodological quality was assessed using the Quality Assessment Tool for Quantitative Studies.
Results Of 6539 articles, only 34 met inclusion criteria. All were observational, used manikins, and were classified as weak in global methodological quality. Compared with standing, several studies suggested the kneeling posture may be associated with more effective and efficient CC. Evidence regarding the optimal patient height, including potential anthropometric-based adjustments, remains limited. Findings across the included studies indicated that variations in hand position appeared to have minimal influence on CC quality. Some studies reported decreased CC quality when rescuers performed CC while walking.
Conclusions The available evidence suggested that performing CC while kneeling on a firm surface may be beneficial when feasible. Future research is needed to further evaluate the impact of bed height, self-selected rescuer position, and their relevance to emergency practice.
Objective We investigated the possible association between lower serum lactate to albumin ratio upon hospital arrival and out-of-hospital cardiac arrest (OHCA) outcome.
Methods Records from the Japanese Association for Acute Medicine–Out-of-Hospital Cardiac Arrest (JAAM-OHCA) Registry were used for this multicenter observational study. Enrolled patients were ≥18 years old with OHCA of medical etiology who were hospitalized after spontaneous circulation returned between June 1, 2014, and December 31, 2021. We excluded those with missing data or those who failed to meet predefined inclusion criteria. The primary outcome was a cerebral performance category scale of 1 or 2 which indicated 30-day survival with favorable neurological outcome. Patients were divided into quartiles based on serum lactate to albumin ratios. The multivariable logistic regression analysis included adjustment for multiple factors.
Results Data from 4,413 patients were analyzed. The primary outcome was achieved by 558 of 1,104 patients (50.5%) in the first quartile (lactate to albumin ratio, ≤2.23), 240 of 1,111 patients (21.6%) in the second quartile (lactate to albumin ratio >2.23–3.39), 96 of 1,096 patients (8.8%) in the third quartile (lactate to albumin ratio >3.39–4.70), and 24 of 1,102 patients (2.2%) in the fourth quartile (lactate to albumin ratio, >4.70). Adjusted odds ratios (95% confidence intervals) for the primary outcome in the second, third, and fourth quartile compared with the first quartile were 0.33 (0.26–0.42), 0.19 (0.14–0.26), and 0.07 (0.04–0.11), respectively.
Conclusion A statistically significant association between categorization in the lower lactate to albumin ratio quartile group and favorable neurological outcome after OHCA was identified.
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Objective To determine whether a transesophageal echocardiography (TEE) probe can accurately measure temperature and be used to monitor temperature changes over time without overheating in an experimental model of hypothermia and rewarming. Methods A 6-L water bath was heated with a sous vide immersion circulator to 24, 28, 32, and 36 °C to simulate severe hypothermia, moderate hypothermia, mild hypothermia, and normothermia, respectively. A TEE probe, esophageal temperature probe, and bladder temperature probe were used to measure temperature every 60 seconds for 15 minutes. Results The TEE probe reported temperatures with a mean difference of 0.60 °C (95% confidence interval [CI], 0.51 to 0.69 °C) compared to the sous vide immersion circulator. The esophageal probe and bladder probe reported temperatures with a mean difference of –0.19 °C (95% CI, –0.23 to –0.14 °C) and –0.20 °C (95% CI, –0.26 to –0.14 °C), respectively. Conclusion During this simulation, the TEE tip temperature did not increase beyond the expected changes produced by water temperature. The probe temperature was less accurate than the esophageal and bladder temperature probes but demonstrated precision in monitoring temperature changes and stable hypothermia. Based on this study, TEE probes should not be relied upon for an accurate initial temperature but can likely be used to monitor changes in temperature over time.
This bibliometric analysis of the 100 most cited articles on experimental cardiac arrest models in rats identifies key contributors, publication trends, research themes, and collaboration networks. A comprehensive literature search of the Web of Science database was performed on June 11, 2024, using keywords related to cardiac arrest and rat models. The top 100 most cited articles were analyzed using the biblioshiny web application from the bibliometrix R ver. 4.2.3 and categorized by primary research focus. The articles were published from 1980 to 2022 and involved 416 authors and 44 journals, averaging 106.7 citations each. The primary research themes were neurology (72%), organ transplantation (7%), cardiovascular system (6%), Cardiopulmonary resuscitation outcomes after local anesthetic toxicity (4%), and other topics (5%). The United States, Japan, and Germany were leading contributors. Major clusters identified include “cerebral ischemia and outcomes,” “brain imaging metrics,” and “blood brain barrier.” The most commonly used methodologies for cardiac arrest induction were asphyxia, induction by magnesium or potassium chloride, and electrical stimulation. This first bibliometric analysis on this topic reveals the dominance of neuroscience in experimental cardiac arrest models in rats. High-impact journals such as the Journal of Cerebral Blood Flow and Metabolism play critical roles in disseminating significant research. The study highlights substantial gaps in global research engagement, with minimal contributions from lower income countries and few international collaborations. This analysis provides a roadmap for future research and opportunities for more extensive international and interdisciplinary collaboration, always with a focus on scientific rigor.
Objective This study assessed the efficacy of electrocardiogram (ECG) compared to pulse oximetry (PO) in detecting heart rate (HR) during high-risk newborn resuscitation. Methods A prospective observational study was performed with high-risk delivery cases to measure the time required for HR detection. A conventional PO and a standard ECG monitor were used for HR assessment. Results Forty-one infants were analyzed in the study, and 11 needed resuscitation. The study population was divided according to gestational age (GA): 9 were GA <32 weeks, 28 were GA 32–35 weeks, and 4 were GA ≥36 weeks. Time from ECG placement to HR detection (median, 30 seconds; interquartile range [IQR], 20–43.5 seconds) was significantly faster than that from PO placement (median, 125 seconds; IQR, 100–175 seconds; P<0.001). Time from ECG placement to HR detection was shortest in infants with GA <32 weeks at birth (19 seconds [IQR, 11.5–30.0] for GA <32 weeks vs. 34.5 seconds [IQR, 25.0–44.3] for GA 32–35 weeks vs. 39.5 seconds [IQR, 30.0–64.8] for GA ≥36 weeks; P=0.039). Conclusion ECG effectively evaluated HR during neonatal resuscitation compared to PO. Low- GA infants who require resuscitation may benefit from HR evaluation with nearby standard ECG.
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While nonocclusive mesenteric ischemia (NOMI) has been reported in a significant percentage of adults who were resuscitated after cardiac arrest, it is rare in children. This report presents the first known Japanese case of pediatric NOMI after return of spontaneous circulation following cardiac arrest. A 16-month-old boy experienced cardiac arrest due to asphyxiation from foreign bodies in the airway. After receiving 10 doses of adrenaline, with a maximum arrest time of 95 minutes, the patient achieved return of spontaneous circulation. However, 40 hours after onset, the patient developed NOMI, resulting in refractory hypotensive shock with decreased blood pressure, distended abdomen, and increased intravesical pressure. The patient was successfully rescued with two laparotomies and was discharged. Although NOMI is uncommon in children, appropriate treatment can be lifesaving.
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Objective Family presence during resuscitation (FPDR) is an established part of family-centered care. However, how physicians are educated about FPDR is relatively unclear. We aim to review the current status of FPDR simulation for physicians and medical students. Methods A scoping review of literature published from 1999 to May 5, 2023, and written in English was undertaken. Articles were searched for using combinations of various family-, resuscitation-, and simulation-related words as keywords, respectively. Results Eight articles were included in the final review. This review of FPDR simulation for physicians and medical students revealed findings in three categories: measuring cardiopulmonary resuscitation quality, investigating participant responses after FPDR simulation, and extracting exemplar good-communication elements. First, in four studies measuring resuscitation quality, physicians participated in adult resuscitation, and resuscitation quality was reduced with a family witness showing an overt reaction. Second, in three studies investigating the response to simulation training, interprofessional teams participating in pediatric resuscitation had negative responses to FPDR simulation. Third, in one study, good-communication elements during FPDR were observed during infant simulation, in which interprofessional teams participated. To the best of our knowledge, FPDR simulation training for medical students has not been reported. Conclusion Our literature review highlights a gap in FPDR simulation involving physicians and/ or medical students. Physicians were more concerned with resuscitation quality than supporting families during resuscitation simulations. Medical students should be considered as participants for FPDR simulation. More high-evidence studies with interprofessional teams that include physicians and/or medical students are needed to evaluate curriculum design and participant-response changes following FPDR simulation.
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