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Published by Korean Association of Cardiopulmonary Resuscitation · GRADE
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.
Key Takeaways
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).
For patients with cardiac arrest caused by acute hyperkalemia, intravenous administration of insulin and glucose is recommended.
Current evidence is insufficient to recommend for or against the administration of intravenous bicarbonate in patients with cardiac arrest caused by acute hyperkalemia.
Evidence remains inadequate to support or oppose the use of intravenous calcium in patients with cardiac arrest caused by acute hyperkalemia.
Thrombolytics may be administered if pulmonary embolism is suspected as the cause of cardiac arrest.
When pulmonary embolism is confirmed, thrombolytics, surgical embolectomy, or percutaneous mechanical thrombectomy may be considered.
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).
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.
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.
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.
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.
If a patient requiring defibrillation is in the prone position and cannot be turned immediately, defibrillation may be performed in this position.
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.
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.
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
Therapeutic Area
Emergency MedicineGuideline Scope
Care Settings
Special Populations
System: GRADE
Evidence Distribution
Evidence Levels
Recommendation Strength
Contraindications
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.
Difficulty
advanced
Estimated Read Time
30 minutes
Learning Paths