Copublishing of the Pediatric and Neonatal Portionsof the 2015 International Consensus onCardiopulmonary Resuscitation and EmergencyCardiovascular Care Science With TreatmentRecommendations and the 2015 American HeartAssociation Guidelines Update for CardiopulmonaryResuscitation and Emergency Cardiovascular Care

For 20 years, the American Heart Association (AHA) and AmericanAcademyofPediatrics (AAP)havepartnered in theevaluationofpediatricresuscitation science through the International Liaison Committee onResuscitation (ILCOR), development of Emergency Cardiovascular Care(ECC) Guidelines, and implementation of educational programs.

The new2015 International ConsensusonCardiopulmonary Resuscitationand Emergency Cardiovascular Care Science With Treatment Recom-mendations are copublished in Resuscitation (http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000270) and Circulation (http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000252). Additionally,the 2015 American Heart Association Guidelines Update for Cardiopulmo-nary Resuscitation and Emergency Cardiovascular Care are now available(http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000252). Inan effort to make the science and guidelines easily accessible to thepediatric community, the Pediatrics editorial board has co-published thepediatric and neonatal portions of these statements since 2000.

Readers of the following excerpts are encouraged to reference the full2015 supplements. The full supplements include several other relevanttopic areas including ethics, education and training, and first-aid.

TOWARD INTERNATIONAL CONSENSUS ON SCIENCE

The International Liaison Committee on Resuscitation (ILCOR) wasformed in 1992 and currently includes representatives from theAmerican Heart Association (AHA), the European Resuscitation Council,the Heart and Stroke Foundation of Canada, the Australian and NewZealand Committee on Resuscitation, Resuscitation Council of SouthernAfrica, the InterAmericanHeartFoundation,andtheResuscitationCouncilofAsia. The ILCOR mission is to identify and review international science andinformation relevant to cardiopulmonary resuscitation (CPR) and emer-gency cardiovascular care (ECC) and to offer consensus on treatmentrecommendations. Since 2000, researchers from the ILCOR membercouncils have evaluated and reported their International Consensus onCPR and ECC Science With Treatment Recommendations (CoSTR) in5-year cycles.

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EVIDENCE EVALUATION PROCESS

The 2015 evidence evaluation processbegan in 2012 when ILCOR representa-tives formed 7 task forces: Basic LifeSupport (BLS), Advanced Life Support(ALS), Acute Coronary Syndromes (ACS),Pediatric BLS and ALS, Neonatal Re-suscitation, Education, Implementationand Training (EIT), and for the first time,First Aid. The 2015 CoSTR publication isnot a comprehensive review of everyaspect of resuscitation medicine: not alltopics covered in 2010were re-reviewedin 2015. All questions reviewed in 2010 inboth International Consensus on Car-diopulmonary Resuscitation and Emer-gency Cardiovascular Care Science WithTreatment Recommendations and the2010 council-specific guidelines forCPR and ECC (including those pub-lished by the AHA) were reassessed bythe Pediatric and Neonatal ILCOR TaskForces. The Pediatric and NeonatalILCOR Task Forces formulated 21 and26 (respectively) priority questionsto address for the 2015 systematicreviews.

Each task force performed detailedsystematic reviews based on the rec-ommendations of the Institute of Med-icineof theNationalAcademies1andusingthe methodological approach proposedby the Grading of Recommendations, As-sessment, Development, and Evaluation(GRADE) Working Group.2 Each task forceidentified and prioritized the ques-tions to be addressed (using the PICO[population, intervention, comparator,outcome] format)3 and identified theoutcomes to be reported. Then, withthe assistance of information scien-tists, a detailed search for relevantarticles was performed in each of 3online databases (MEDLINE, Embase,and the Cochrane Library).

By using detailed inclusion and exclu-sion criteria, articleswere screened forfurther evaluation. The reviewers foreach question created a reconciled riskof bias assessment for each of the in-

cluded studies, using state-of-the-arttools: Cochrane and GRADE for random-ized controlled trials (RCTs),4 Quality As-sessment of Diagnostic Accuracy Studies(QUADAS)-2 for studies of diagnosticaccuracy,5 and GRADE for observationaland interventional studies that informboth therapy and prognosis questions.6

Using the online GRADE Guideline Devel-opment Tool, the evidence reviewerscreated evidence profile tables7 to facil-itate evaluation of the evidence in sup-port of each of the critical and importantoutcomes. The quality of the evidence (orconfidence in the estimate of the effect)was categorized as high, moderate, low,or very low,8 based on the study meth-odologies and the 5 core GRADE domainsof risk of bias, inconsistency, indirectness,imprecision, and other considerations(including publication bias).2

These evidence profile tableswere thenused to create a written summary ofevidence for each outcome (the Con-sensus on Science statements). Thesestatements were drafted by the evi-dence reviewers and then discussedand debated by the task forces untilconsensus was reached. Whenever pos-sible, consensus-based treatment rec-ommendations were created. Theserecommendations (designated as strongor weak, and either for or against atherapy, prognostic tool or diagnostictest) were accompanied by an overallassessment of the evidence, and astatement from the task force aboutthe values and preferences that un-derlie the recommendations.

Each systematic review’s CoSTR state-ment used wording consistent with thewording recommended by GRADE andused throughout the CoSTR publica-tion. Weak recommendations use theword suggest, as in “We suggest…”

Strong recommendations are indicatedby the use of the word recommend, asin, “We recommend…”

Public comment was sought at 2 stagesin the process. Initial feedback was

sought about the specific wording ofthePICOquestionsand the initial searchstrategies, and subsequent feedbackwas sought after creation of the initialdraft consensus on science statementsand treatment recommendations.9

For a more thorough discussion of thisprocess, the reader is referred toPart2:Evidence Evaluation and Managementof Potential Conflicts of Interest. (http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000271).

MANAGEMENT OF POTENTIALCONFLICTS OF INTEREST

A rigorous conflict of interest (COI)management policy was followed at alltimes. Anyone involved in anypart of the2015 process disclosed all commercialrelationships and other potential (in-cluding intellectual) conflicts; in total,the AHA processed more than 1000 COIdeclarations. These disclosures wereconsidered during the assignment oftask force co-chairs and members,writing group co-chairs, and otherleadership roles. In keeping with theAHA COI policy, a majority of the mem-bers of each task force writing grouphad to be free of relevant conflicts.Commercial and potential intellectualrelationships were also screened forconflicts in assigning evidence review-ers for each systematic review.

From Consensus on Science toGuidelines

ILCORpublishes internationalconsensusstatements that summarize the scienceof resuscitation and first aid and, wher-ever possible, treatment recommen-dations. ILCOR member organizationssubsequently publish resuscitation guide-lines that are consistentwith the sciencein the consensuspublication, butmaybemodified because of geographic, eco-nomic and system differences, the avail-ability of medical devices and drugs, andthe ease or difficulty of training. All ILCORmember organizations are committed tominimizing international differences in

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resuscitation practice and to optimizingthe effectiveness of resuscitation prac-tice, instructionalmethods, teachingaids,and training networks.

The recommendations of the ILCOR 2015ConsensusConferenceconfirmthesafetyand effectiveness of various current ap-proaches, acknowledgeotherapproachesas ineffective, and introduce new treat-ments resulting from evidence-basedevaluation. Recommendations reviewedand published in 2010 but not in 2015remain the official positions of bothILCOR and the AHA.

2015 AMERICAN HEARTASSOCIATION GUIDELINES UPDATEFOR CARDIOPULMONARYRESUSCITATION AND EMERGENCYCARDIOVASCULAR CARE

Publication of the 2015 American HeartAssociation (AHA) Guidelines Update forCardiopulmonary Resuscitation (CPR)and Emergency Cardiovascular Care(ECC) marks 49 years since the first CPRguidelines were published in 1966 by anAd Hoc Committee on CardiopulmonaryResuscitation established by the NationalAcademy of Sciences of the National Re-

search Council.10 Since that time, periodicrevisions to the Guidelines have been pub-lished by the AHA in 1974,11 1980,12 1986,13

1992,14 2000,15 2005,16 2010,17 and now2015. The 2015 AHA Guidelines Update forCPR and ECC focuses on topics with sig-nificant new science or ongoing contro-versy, and so serves as an Update to the2010AHAGuidelines forCPRandECC ratherthan a complete revision of the Guidelines.

The 2015 Guidelines Update marks thebeginning of a new era for the AHAGuidelines for CPR and ECC, because theGuidelines will transition from a 5-year

Table 1. Applying Class of Recommendations and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in PatientCare*

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cycle of periodic revisions and updates toa Web-based format that is continuouslyupdated. Moving forward, these Guide-lineswillbeupdatedbyusingacontinuousevidence evaluation process to facilitatemore rapid translation of new scientificdiscoveries into daily patient care.

EVIDENCE REVIEW AND GUIDELINESDEVELOPMENT PROCESS

The AHA continues to partner with theInternational Liaison Committee onResuscitation (ILCOR) in the evidencereview process. The recommendationsof the ILCOR 2015 CoSTR were used toinform the recommendations in the2015 AHA Guidelines Update for CPRand ECC. The wording of these rec-ommendations is based on the AHAclassification system for evidentiaryreview.

The 2015 AHA Guidelines Update forCPR and ECC contains 7 pediatric,29 PALS and 48 neonatal classified rec-ommendations. There are 16 ClassI recommendations (19%), 14 Class IIarecommendations (17%), 52 ClassIIb recommendations (62%) and 2 ClassIII recommendation (2%). Overall, 1 arebased on Level of Evidence (LOE) A, 3are based on LOE B, 24 are based on LOEB-R, 7 LOE B-NR, 9 LOE C, 37 are based onLOE C-LD, and 13 are based on LOE C-EO.These results highlight the persistentknowledge gap in resuscitation sciencethat needs to be addressed throughexpanded research initiatives and fund-ing opportunities.

SUMMARY

This 2015 AHA Guidelines Update marksthe transition from periodic review andpublication of new science-based rec-ommendation to a more continuousprocess of evidence evaluation andguideline optimization designed tomore rapidly translate new science intoresuscitation practice that will savemore lives. Survival from both IHCA andOHCA has increased over the past de-

cade, but there is still tremendous po-tential for improvement. It is clear thatsuccessful resuscitation depends oncoordinated systems of care that startwith prompt rescuer actions, requiredelivery of high-quality CPR, and con-tinue throughoptimizedACLSandpost–cardiac arrest care. Systems thatmonitorand report quality-of-caremetricsand patient-centered outcomes will havethe greatest opportunity through qualityimprovement to save the most lives.

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2. Schünemann H, Bro _zek J, Guyatt G,Oxman A. GRADE Handbook . 2013. http://www.guidelinedevelopment.org/handbook/.Accessed May 6, 2015.

3. Chapter 5: Defining the review questions anddeveloping criteria for including studies.In: O’Connor D, Higgins J, Green S, eds.Cochrane Handbook for Systematic Reviewsof Interventions. Version 5.1.0. 2011. http://handbook.cochrane.org/. Accessed May 6, 2015.

4. 8.5 The Cochrane Collaboration’s tool for assess-ing risk of bias; Chapter 8: Assessing risk of biasin included studies. In: Higgins JPT, Altman DG,Sterne J, eds. Cochrane Handbook for SystematicReviews of Interventions. Version 5.1.0. 2011. http://handbook.cochrane.org/. Accessed May 6, 2015.

5. Whiting PF, Rutjes AW, Westwood ME, MallettS, Deeks JJ, Reitsma JB, et al. QUADAS-2:a revised tool for the quality assessmentof diagnostic accuracy studies. Ann InternMed. 2011;155:529–536.

6. Schünemann H, Bro_zek J, Guyatt G, Oxman A. 5.2.1Study limitations (risk of bias). In: GRADE Hand-book. 2013. http://www.guidelinedevelopment.org/handbook/#h.m9385o5z3li7. Accessed May 6, 2015.

7. Evidence Prime Inc. GDT–Guideline Develop-ment Tool. http://www.guidelinedevelopment.org/. Accessed May 6, 2015.

8. Schunemann HJ, Oxman AD, Brozek J, GlasziouP, Jaeschke R, Vist GE, Williams JW Jr., Kunz R,Craig J, Montori VM, Bossuyt P, Guyatt GH.Grading quality of evidence and strength ofrecommendations for diagnostic tests andstrategies. BMJ. 2008;336:1106–1110.

9. American Heart Association, American StrokeAssocation, International Liaison Committee onResuscitation (ILCOR), SEERS. ILCOR ScientificEvidence Evaluation and Review System. 2015.

https://volunteer.heart.org/apps/pico/Pages/default.aspx. Accessed May 10, 2015.

10. Cardiopulmonary resuscitation. JAMA. 1966;198:372–379.

11. Standards for cardiopulmonary resuscitation(CPR) and emergency cardiac care (ECC). 3.Advanced life support. JAMA. 1974;227:Suppl:852–860.

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13. Standards and guidelines for Cardiopul-monary Resuscitation (CPR) and EmergencyCardiac Care (ECC). National Academy ofSciences - National Research Council. JAMA.1986;255:2905–2989.

14. Guidelines for cardiopulmonary resuscitationand emergency cardiac care. Emergency CardiacCare Committee and Subcommittees, AmericanHeart Association. JAMA. 1992;268:2135–2302.

15. American Heart Association in collaboration withInternational Liaison Committee on Resuscitation.Guidelines 2000 for Cardiopulmonary Re-suscitation and Emergency CardiovascularCare: International Consensus on Science.Circulation. 2000;102 (suppl):I1–I384.

16. 2005 American Heart Association Guide-lines for Cardiopulmonary Resuscitationand Emergency Cardiovascular Care. Cir-culation. 2005;112:IV1–203.

17. Field JM, Hazinski MF, Sayre MR, ChameidesL, Schexnayder SM, Hemphill R, Samson RA,Kattwinkel J, Berg RA, Bhanji F, Cave DM,Jauch EC, Kudenchuk PJ, Neumar RW,Peberdy MA, Perlman JM, Sinz E, Travers AH,Berg MD, Billi JE, Eigel B, Hickey RW, KleinmanME, Link MS, Morrison LJ, O’Connor RE,Shuster M, Callaway CW, Cucchiara B, FergusonJD, Rea TD, Vanden Hoek TL. Part 1: executivesummary: 2010 American Heart AssociationGuidelines for Cardiopulmonary Resuscitationand Emergency Cardiovascular Care. Circula-tion. 2010;122:S640–656.

CONTRIBUTORS 2015 ILCORNEONATAL EVIDENCE REVIEWERS

Khalid Aziz; David W. Boyle; Steve Byrne;Chris Colby; Peter Davis, Maria Fernandade Almeida; Hege L. Ersdal; Marilyn B.Escobedo; Qi Feng; RuthGuinsburg; Louis P.Halamek;TetsuyaIsayama;VishalS.Kapadia;John Kattwinkel; Han-Suk Kim; Henry C.Lee; Helen G. Liley; Jane E. McGowan;Douglas D. McMillan; Lindsay Mildenhall;Susan Niermeyer; Colm P.F. O’Donnell;Jeffrey M. Perlman; Yacov Rabi; StevenA. Ringer; Nalini Singhal; Ben J. Stenson;Marya L. Strand; Takahiro Sugiura; Edgardo

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Szyld; Masanori Tamura; DanieleTrevisanuto; Enrique Udaeta; SithembisoVelaphi; Gary M. Weiner, Myra H. Wyckoff;Jonathan Wyllie; Cheo L. Yeo.

2015 Pediatric ILCOR EvidenceReviewers

Richard Aickin; Dianne L. Atkins; MarcBerg; Dominique BIarent; RobertBingham; ThomazBittencourt Couto; JosBruinenberg; Mark Coulthard; StuartDalziel; Allan R. de Caen; Jonathan Duff;Jonathan Egan; Christoph Eich; ErickaFink; Stuart Friess; Anne-MarieGuerguerian; Takanari Ikeyama; MonicaE. Kleinman; David Kloeck; GraemeMacLaren; Ian K. Maconochie; BradMarino; Mary McBride; Peter A.Meaney; Vinay M. Nadkarni; KeeChong Ng; Gabrielle Nuthall; Gene Ong;Melissa Parker; Tia Raymond; Amelia G.Reis; Corsino Rey; Antonio Rodriguez-Nunez; Steven M. Schexnayder; AudreyShibata; Naoki Shimizu; Fernanda Sa;Janice Tijssen; Ravi Thiagarajan; AlexisTopjian; Javier Urbano; Remigio Veliz.

2015 International Consensus onCardiopulmonary Resuscitationand Emergency CardiovascularCare Science with TreatmentRecommendations, Part 1,Executive Summary

Mary Fran Hazinski, Co-Chair; JerryNolan, Co-Chair; Richard AickIn; FarhanBhanji; John Billi; Clifton W. Callaway;Maaret Castrén; Allan R. de Caen;Judith Finn; Sandra Iverson; EddyLang; Swee Han Lim; Ian Maconochie;William Montgomery; Peter Morely;Vinay M. Nadkarni; Robert Neumar;Nikolaos Nikolaou; Gavin Perkins;

Jeffrey M. Perlman; Nici Singletary,Jasmeet Soar; Andrew Travers; MichelleWelsford; Jonathan Witt; Jonathan Wylie;David Zideman.

2015 International Consensus onCardiopulmonary Resuscitation andEmergency Cardiovascular CareScience with TreatmentRecommendations, Part 6,Pediatric

Allan R. de Caen, Co-Chair; Ian K.Maconochie, Co-Chair; Richard Aickin;Dianne L. Atkins; Dominique Biarent;Anne-Marie Guerguerian; Monica E.Kleinman; David A. Kloeck; Peter A.Meaney; Vinay M. Nadkarni; Kee- ChongNg; Gabrielle Nuthall; Amelia G. Reis;Naoki Shimizu; James Tibballs; RemigioVeliz Pintos.

2015 International Consensus onCardiopulmonary Resuscitationand Emergency CardiovascularCare Science with TreatmentRecommendations, Part 7,Neonatal Resuscitation

JeffreyM. Perlman, Co-Chair; JonathanWyllie, Co-Chair; John Kattwinkel; MyraH. Wyckoff; Khalid Aziz; Ruth Guinsburg;Han-Suk Kim; Helen G. Liley; LindsayMildenhall; Wendy M. Simon; EdgardoSzyld; Masanori Tamura; SithembisoVelaphi.

2015 American Heart AssociationGuidelines Update forCardiopulmonary Resuscitationand Emergency CardiovascularCare, Part 1, Executive Summary

Robert W. Neumar; Dianne L. Atkins;Farhan Bhanji; Steven C. Brooks; Clifton

W. Callaway; Allan R. de Caen; Monica E.Kleinman; Steven L. Kronick; Eric J.Lavonas; Mark S. Link; Mary E. Mancini;LaurieMorrison;RobertO’Connor; Eunice“Nici” M. Singletary; Myra H. Wyckoff;Mary Fran Hazinski.

2015 American Heart AssociationGuidelines Update forResuscitation and EmergencyCardiovascular Care, Part 11,Pediatric Basic Life Support

Dianne L. Atkins, Chair; Stuart Berger;Jonathan P. Duff; John C. Gonzales;Benny L. Joyner; Peter A. Meaney; DanaE. Niles; Elizabeth A. Hunt; RicardoA Samson; Steven M. Schexnayder.

2015 American Heart AssociationGuidelines Update forResuscitation and EmergencyCardiovascular Care, Part 12,Pediatric Advanced LifeSupport

Allan R. de Caen, Chair; Marc D. Berg;Leon Chameides; Cheryl K. Gooden;Robert W. Hickey; Halden F. Scott;Robert M. Sutton; Janice A. Tijssen;Alexis Topjian; Élise W. van derJagt; Ricardo A. Samson; Steven M.Schexnayder.

2015 American Heart AssociationGuidelines Update for Resuscitationand Emergency CardiovascularCare, Part 13, Neonatal LifeSupport

Myra H. Wyckoff, Chair; Khalid Aziz;Marilyn B. Escobedo; Vishal S. Kapadia;John Kattwinkel; Jeffrey M. Perlman;Wendy M. Simon; Gary M. Weiner;Jeanette G. Zaichkin.

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DOI: 10.1542/peds.2015-3373B originally published online October 14, 2015; 2015;136;S83Pediatrics 

Emergency Cardiovascular CareAssociation Guidelines Update for Cardiopulmonary Resuscitation and

Care Science With Treatment Recommendations and the 2015 American HeartConsensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Copublishing of the Pediatric and Neonatal Portions of the 2015 International

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Care Science With Treatment Recommendations and the 2015 American HeartConsensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Copublishing of the Pediatric and Neonatal Portions of the 2015 International

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