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2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 5. Cardiac arrest in special circumstances.

Published by Korean Association of Cardiopulmonary Resuscitation · GRADE

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Summary

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The 2025 Korean Guidelines for Cardiopulmonary Resuscitation (Part 5) provide updated clinical recommendations for managing cardiac arrest under special circumstances. Key updates include the administration of intravenous insulin and glucose for hyperkalemia-induced cardiac arrest (while evidence remains insufficient for bicarbonate or calcium), consideration of thrombolytic therapy for suspected or confirmed pulmonary embolism, and the limited routine use of naloxone for opioid-related cardiac arrest unless true cardiac arrest is uncertain. It also provides guidance on prone CPR (supporting its use in intubated patients where repositioning is difficult/unsafe, and emphasizing immediate supination for non-intubated patients), alongside protocols for asthma, anaphylaxis, pregnancy, drowning, severe hypothermia, electric shock, PCI-related arrest, cardiac tamponade, and post-cardiac surgery arrest.

Cardiopulmonary resuscitationHeart arrestSudden cardiac death

Key Takeaways

  • 1
    Intravenous insulin and glucose are recommended for hyperkalemia-induced cardiac arrest, but evidence for bicarbonate or calcium is insufficient.
  • 2
    Thrombolytics should be considered for suspected pulmonary embolism-related cardiac arrest, with additional mechanical or surgical options for confirmed cases.
  • 3
    Routine naloxone is not supported during ALS for confirmed opioid overdose cardiac arrest, but may be used when true cardiac arrest is uncertain.
  • 4
    Prone CPR is acceptable for intubated patients when immediate supination is unsafe or difficult, guided by invasive arterial pressure or ETCO2.
  • 5
    Immediate supination for CPR is strongly recommended for non-intubated patients in prone position.
  • 6
    Prompt resuscitative hysterotomy/cesarean section is indicated within 5 minutes of maternal cardiac arrest when gestation exceeds 20 weeks.

What's New in This Version

The 2025 guidelines update the 2020 versions by introducing clearer recommendation strengths and certainty-of-evidence grading. Significant changes include specific recommendations for hyperkalemia (recommending insulin/glucose but noting insufficient evidence for bicarbonate/calcium) and prone CPR (supporting prone chest compressions in intubated patients and strongly recommending immediate supination for non-intubated patients).

Key Recommendations

Cardiac arrest caused by hyperkalemia

  • REC-01

    For patients with cardiac arrest caused by acute hyperkalemia, intravenous administration of insulin and glucose is recommended.

    weak recommendationEvidence: very low certainty of evidencePharmacological intervention
  • REC-02

    Current evidence is insufficient to recommend for or against the administration of intravenous bicarbonate in patients with cardiac arrest caused by acute hyperkalemia.

    weak recommendationEvidence: very low certainty of evidencePharmacological intervention
  • REC-03

    Evidence remains inadequate to support or oppose the use of intravenous calcium in patients with cardiac arrest caused by acute hyperkalemia.

    weak recommendationEvidence: very low certainty of evidencePharmacological intervention

Cardiac arrest caused by pulmonary embolism

  • REC-04

    Thrombolytics may be administered if pulmonary embolism is suspected as the cause of cardiac arrest.

    weak recommendationEvidence: very low certainty of evidencePharmacological intervention
  • REC-05

    When pulmonary embolism is confirmed, thrombolytics, surgical embolectomy, or percutaneous mechanical thrombectomy may be considered.

    weak recommendationEvidence: very low certainty of evidenceMechanical/Surgical/Pharmacological intervention

Cardiac arrest caused by opioid toxicity

  • REC-06

    In patients with cardiac arrest caused by opioid toxicity, existing evidence does not support administering opioid-specific therapies (e.g., naloxone) in addition to standard resuscitative care during advanced life support (ALS).

    Evidence: insufficient evidencePharmacological intervention
  • REC-07

    If the rescuer is unsure whether a patient with suspected opioid toxicity is in true cardiac arrest, an opioid antagonist (e.g., naloxone) may be administered.

    good practice statementPharmacological intervention

Prone cardiopulmonary resuscitation

  • REC-08

    In patients who experience cardiac arrest in the prone position, prone cardiopulmonary resuscitation (CPR) may be attempted if the patient is intubated, and it is difficult or dangerous to turn the patient immediately to the supine position.

    good practice statementResuscitation position
  • REC-09

    Invasive arterial pressure or end-tidal carbon dioxide (ETCO2) partial pressure monitoring can serve as useful indicators for monitoring perfusion pressure during prone CPR and may assist in determining when to turn the patient to the supine position for CPR.

    good practice statementMonitoring guidance
  • REC-10

    If a patient with cardiac arrest in the prone position does not have an advanced airway in place, it is suggested that the patient be turned to the supine position immediately for CPR.

    strong recommendationEvidence: low certainty of evidenceResuscitation position
  • REC-11

    If a patient requiring defibrillation is in the prone position and cannot be turned immediately, defibrillation may be performed in this position.

    good practice statementElectrical therapy

Drowning

  • REC-12

    For patients who develop hypoxia during transport to the hospital, supplemental oxygen should be provided to maintain an oxygen saturation of at least 94%. Endotracheal intubation may be performed if necessary.

    weak recommendationEvidence: very low certainty of evidenceAirway/Oxygenation
  • REC-13

    In cases of moderate or severe acute lung injury following drowning, noninvasive ventilation may be considered as an alternative to mechanical ventilation in hemodynamically stable patients with a Glasgow Coma Scale score of >= 12.

    weak recommendationEvidence: very low certainty of evidenceVentilation support

Scope & Objectives

Clinical Topic

Cardiopulmonary Resuscitation (CPR) in special circumstances

Objectives

To update the Korean guidelines for cardiac arrest under special circumstances by incorporating new scientific evidence and expert consensus to clarify when clinicians should modify standard resuscitation algorithms.

Target Patient Population

Patients experiencing cardiac arrest in special circumstances, including acute hyperkalemia, pulmonary embolism, opioid toxicity, prone position, asthma, anaphylaxis, pregnancy, drowning, severe hypothermia, electric shock and lightning, during percutaneous coronary intervention, cardiac tamponade, and after cardiac surgery.

Diagnostic Criteria

For pulmonary embolism, the guidelines note that right atrial and right ventricular dilation on ultrasound during CPR is insufficient for diagnosis. For severe hypothermia, the guideline notes that heart rate and respiratory rate decrease rapidly, making cardiac arrest difficult to determine, requiring continued CPR unless rigor mortis or injury incompatible with life is present.

Target Providers

Healthcare providersRescuersEmergency medical services (EMS) teamsSpecialized procedure teams

Patient Criteria & Setting

Therapeutic Area

Emergency Medicine

Guideline Scope

Clinical Practice Guideline

Care Settings

Emergency DepartmentIntensive Care Unit (ICU)Operating RoomPre-hospital / Out-of-hospitalCardiac Catheterization Laboratory

Special Populations

Pregnant womenDrowning victimsHypothermia patientsPediatric patientsOpioid overdose patientsAsthma patientsAnaphylaxis patients

Evidence Grading

System: GRADE

Evidence Distribution

5good_practice_statement
1strong_recommendation_low_certainty
7weak_recommendation_very_low_certainty

Evidence Levels

lowOur confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
highWe are very confident that the true effect lies close to that of the estimate of the effect.
moderateWe are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
very_lowWe have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

Recommendation Strength

weakSuggested; benefits and risks are closely balanced or uncertain.
strongHighly recommended; benefits clearly outweigh risks, or vice versa.
good_practice_statementA message that is considered key to clinical practice but is not graded because there is no direct evidence or it is considered standard clinical common sense.

Safety & Contraindications

Contraindications

  • Mechanical CPR is not recommended in pregnant women.
  • Rapid administration of potassium is not recommended for hypokalemia.
  • Subcutaneous injection of epinephrine is not recommended in shock states due to slow absorption.
  • Routine use of antihistamines and steroids is not recommended in the initial treatment of anaphylaxis.

Monitoring Guidance

Invasive arterial pressure or end-tidal carbon dioxide (ETCO2) monitoring to guide perfusion pressure and the timing of repositioning during prone CPR; blood pressure, oxygen saturation, and electrocardiogram (ECG) monitoring during intravenous epinephrine administration for anaphylaxis; fetal monitoring during hypothermia period in pregnant patients.

Authors & Contributors

Tae-Youn KimGyo Jin AhnKyoung-Chul ChaDong-Hyeok KimYoudong SohnYoung SongGyuhong ShimDo Kyun KimYunhee OhJin WiChun Song YounMyung-Lyeol LeeMi Jin LeeByung Kook LeeByung Heon LeeJisook LeeChang Hee LeeHannah LeeYoungbin JangYong Soo JangYoung Hwa JungWoo Jin JungSung Phil ChungGyu Chong ChoJu Sun HeoSung Oh Hwang

Guideline Features

Dosing informationBased on systematic reviewMultidisciplinary

Learning Context

Difficulty

advanced

Estimated Read Time

30 minutes

Learning Paths

Advanced Life SupportEmergency MedicineSpecial Resuscitation CircumstancesCardiac Arrest