The ERC Guidelines 2021: Main Changes (Part 2/7)

The updated Guidelines provide clinical and health policy information including the development of National Cardiac Arrest Registries, technology-use for citizens, and mandatory CPR training in schools.

New technologies, training and citizen involvement among the new themes

The recently published ERC Guidelines 2021 provide updates from a clinical perspective, but also useful information for health policy makers. The development and use of National Cardiac Arrest Registries, the inclusion of technologies for citizen involvement, and mandatory CPR training in schools are some of the most emphasised elements of the new guidelines that add effectiveness to clinical practice in the management of cardiac arrest.

The ERC 2021 Guidelines devote two specific chapters to the epidemiology of cardiac arrest and prevention systems. This is new, as these topics have previously been included within other chapters. The intention is clearly to cover the topics comprehensively and to give them as much prominence as possible.


In the chapter on epidemiology the contributions of the European Registry of Cardiac Arrest (EuReCa) are highlighted. Recommendations are made that will enable health systems to develop and use registries as a platform for improving cardiac arrest response planning. Today, 29 countries are collaborating in EuReCa. About 70% of European countries have registries for out-of-hospital cardiac arrest (OHCA), but the completeness of data collection varies greatly.

National health systems should have registries for cardiac arrest, tracking incidence, type of cases, treatment, and outcome of resuscitation manoeuvres.  Data from the registers should be used for planning the health system response to cardiac arrest. The chapter also discusses post-arrest rehabilitation services, which are currently insufficient in all countries.

The importance of community: Systems-building saves lives

The ERC Guidelines 2021 emphasise the role of communities in preventing out-of-hospital cardiac arrest deaths. Several topics are covered: Chain of Survival, measuring the quality of cardiopulmonary resuscitation, using social media and smartphone apps to engage the community, the World Restart a Heart campaign, the KIDS SAVE LIVES campaign, early warning systems, the role of the dispatch centre and cardiac arrest centres.

The aim of health systems should be to involve the whole community so that every citizen, including children, knows what to do in case of cardiac arrest. The guidelines propose that health systems should promote CPR training initiatives for the whole population. Training of school children in CPR should be mandatory by law across Europe (and beyond).

More lives can only be saved if rapid and effective action is taken in the face of cardiac arrest. But training is not enough, and those who are trained need to be able to intervene quickly. Hence the recommendation includes the use of smartphone technology (social media and apps) to involve so-called first responders (such as trained and untrained lay people, firefighters, police officers and off-duty health workers) who are in the vicinity of a suspected out-of-hospital cardiac arrest.

Dispatch centres should implement standardised criteria and algorithms to determine whether a patient is in circulatory arrest at the time of the call. Operators should provide CPR instructions to callers who recognise that an adult is unresponsive and not breathing normally, focusing on performing chest compressions.

The guidelines indicate that adult patients in out-of-hospital nontraumatic cardiac arrest should be transported to a specialist centre according to local regulations. The patient should be allocated to a hospital with 24-hour availability of highly-skilled intensive care personnel and equipment, to include temperature management, coronary angiogram and neurodiagnostic (CT) examinations.

Clinical practice modifications

Adult patients:

Paediatric patients:

The 2021 ERC Guidelines can be downloaded here: New ERC Guidelines.

An overview of the most important ECR Guidelines 2021 changes is available in this esanum article series:

1. Gräsner JT, Herlitz J, Tjelmeland IBM, Wnent J, Masterson S, Lilja G, Bein B, Böttiger BW, Rosell-Ortiz F, Nolan JP, Bossaert L, Perkins GD. European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe. Resuscitation. 2021 Apr;161:61-79. doi: 10.1016/j.resuscitation.2021.02.007. Epub 2021 Mar 24. PMID: 33773833.
2. Semeraro F, Greif R, Böttiger BW, Burkart R, Cimpoesu D, Georgiou M, Yeung J, Lippert F, S Lockey A, Olasveengen TM, Ristagno G, Schlieber J, Schnaubelt S, Scapigliati A, G Monsieurs K. European Resuscitation Council Guidelines 2021: Systems saving lives. Resuscitation. 2021 Apr;161:80-97. doi: 10.1016/j.resuscitation.2021.02.008. Epub 2021 Mar 24. PMID: 33773834. 
3. Fandler M. Neue Reanimationsleitlinien 2021 (ERC) Zusammenfassung. 25/03/2021