Conflict of Interest Declaration
The International Liaison Committee on Resuscitation (ILCOR) Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. No Task Force members or other authors declared a conflict of interest. The following Task Force members involved in the review declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Gavin Perkins is an author on an included study, the Editor-in-Chief for Resuscitation Plus and Editor for Resuscitation; Janet Bray is an Editor for Resuscitation Plus and member of the Editorial Board of Resuscitation; Theresa Olasveengen is Editor for Resuscitation Plus and member of the Editorial Board of Resuscitation.
Task Force Synthesis Citation
Julie Considine, Carolyn M Zelop, Anastasia Spartinou, Jason Acworth, Stephan Katzenschlager, Janet E. Bray, Tracy Kidd, Theresa M. Olasveengen, Kevin Nation and Gavin D. Perkins on behalf of the International Liaison Committee on Resuscitation (ILCOR) Basic Life Support (BLS); Advanced Life Support (ALS); Pediatric Life Support (PLS); and Education, Implementation and Team (EIT) Task Forces. Clinician Recognition of Cardiac Arrest: A Scoping Review. [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR). October 31, 2026. Available from: http://ilcor.org ;
Methodological Preamble
The continuous evidence evaluation process started with a scoping review on clinician recognition of cardiac arrest. The review was conducted by the ILCOR Basic Life Support (BLS); Advanced Life Support (ALS); Pediatric Life Support (PLS); and Education, Implementation and Team (EIT) Task Forces. Evidence for all settings (out-of-hospital and in-hospital, adult and pediatric) was sought and synthesized in accordance with ILCOR guidance and PRISMA-ScR methodology.
Scoping Review
Considine, J., Zelop, C.M., Spartinou, A., Acworth, J., Katzenschlager, S., Bray, JE., Kidd, T., Olasveengen, TM., Nation, K., Perkins, GD., & on behalf of the International Liaison Committee on Resuscitation (ILCOR) Basic Life Support (BLS); Advanced Life Support (ALS); Pediatric Life Support (PLS); and Education, Implementation and Team (EIT) Task Forces. Clinician Recognition of Cardiac Arrest: A Scoping Review. Resuscitation Plus 2026 [under review submitted 20 October 2026].
PCC
The PCC (Population, Concept, Context)
Population: Health care professionals working in a professional context (for example, but not limited to doctors, nurses, paramedics, EMTs, healthcare workers).
Concept: Recognition of cardiac arrest (and need for CPR or defibrillation) in a patient, visitor or colleague of any age (adults or pediatrics).
Context: Cardiac arrest in any setting (IHCA or EMS witnessed OHCA) including adults or pediatrics.
Outcomes:
• Accurate recognition of cardiac arrest (‘correct diagnosis’)
• Escalation of care
• CPR timing (time to commencement of rescue breaths, first compression, first defibrillation if shockable rhythm)
Study Design: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Simulation studies, studies using healthy volunteers and extracorporeal membrane oxygenation or cardiopulmonary bypass with the intent of cardiac arrest recognition were eligible for inclusion. Animal studies, grey literature and social media, and non-peer reviewed studies, unpublished studies, conference abstracts and trial protocols were excluded. Studies of dispatcher recognition of cardiac arrest or recognition of clinical deterioration without cardiac arrest were excluded. All relevant publications in any language are included as long as there is an English abstract.
Timeframe: All years
Literature search updated to 07/09/2026.
Search Strategies
Articles for review were obtained by searching MEDLINE, CINAHL, EMBASE, and the Cochrane library from inception through 07/09/2026.
Articles are using key terms “cardiac arrest”, “recognition or diagnosis” and “clinical or healthcare professional” including their MESH terms, and Embase exploded terms.
Inclusion and Exclusion Criteria
Inclusion Criteria: Peer-reviewed studies of health care professionals (for example but not limited to doctors, nurses, paramedics, emergency medical technicians, healthcare workers, health profession students) working in a professional context; real-time recognition of actual or simulated cardiac arrest (including need for CPR and/or defibrillation) in a patient, visitor or colleague of any age; and cardiac arrest in any setting (prehospital clinician witnessed out-of-hospital cardiac arrest or in-hospital cardiac arrest).
Exclusion Criteria: Studies of dispatcher-assisted recognition of cardiac arrest; bystander recognition of cardiac arrest (including health care professionals as bystanders); recognition of clinical deterioration without cardiac arrest; and antecedents to, or risk factors for, cardiac arrest.
Data Table
BLS 2101 Clinician recognition CA data tables
Task Force Insights
1. Why this topic was reviewed.
This topic has not been reviewed by ILCOR since 2010,1,2 apart from a systematic review on pulse assessment in pediatric cardiac arrests.3,4 A scoping review was conducted to widen the search beyond breathing and pulse checks.
Prompt recognition of cardiac arrest and initiation of cardiopulmonary resuscitation are crucial to maximizing survival of a cardiac arrest victim. Traditionally, cardiac arrest recognition was based on unresponsiveness, airway opening and assessment of breathing, and palpating for a carotid pulse. Various studies have shown the low accuracy of pulse checks when performed by laypeople and healthcare professionals5-8, leading guidelines for laypeople to eliminate pulse assessment for cardiac arrest recognition. However, some current resuscitation guidelines9 still advise healthcare professionals to assess pulse presence or absence, along with responsiveness and breathing, for cardiac arrest recognition. Furthermore, healthcare professionals may also employ additional modalities to help evaluate suspected cardiac arrest, such as doppler ultrasound, echocardiography, invasive arterial pressure monitoring, capnography or electrocardiography.
ILCOR last reviewed recognition of cardiac arrest in 2010,1,2 and included recognition by both lay rescuers and healthcare professionals. That review examined whether specific clinical features or decision rules, compared with standard assessment, could improve recognition of cardiac arrest in unresponsive adults and children, in both out-of-hospital and in-hospital settings, and help distinguish cardiac arrest from other causes of unresponsiveness, such as seizures, hypoglycaemia and intoxication. The 2010 Treatment Recommendation1,2 stated:
”It is reasonable that lay rescuers and healthcare professionals use the combination of unresponsiveness and absent or abnormal breathing to identify cardiac arrest. Palpation of the pulse as the sole indicator of the presence or absence of cardiac arrest is unreliable. Agonal gasps are common during cardiac arrest and should not be considered normal breathing. The general public and EMS dispatchers should be taught how to recognise agonal gasps as a sign of cardiac arrest.”
No contemporary reviews have comprehensively examined the range of clinical assessment methods used by healthcare professionals to recognize cardiac arrest, including pulse assessment, breathing assessment and cardiac rhythm interpretation. Accordingly, the ILCOR Basic Life Support (BLS) Task Force prioritised this topic for a joint scoping review with the Advanced Life Support (ALS), Pediatric Life Support (PLS), and Education, Implementation and Teams (EIT) Task Forces. The review aims to map the existing evidence on the recognition of cardiac arrest by healthcare professionals and the timely initiation of cardiopulmonary resuscitation (CPR) in adults and children. The review was restricted to healthcare professionals, excluding lay rescuers, because of important differences in clinical knowledge, training and access to assessment equipment between these groups. A scoping review methodology was selected to capture the breadth of monitoring and assessment modalities used by healthcare professionals to recognise cardiac arrest, map the types and characteristics of available evidence, identify emerging research directions, and highlight gaps in the evidence base.
2. Narrative summary of evidence identified
A total of 20 studies were included, grouped into three main assessment categories: pulse assessment (n=10)5-8,10-15 breathing assessment (n=3)11,16,17 and cardiac arrest rhythm recognition (n=8).18-25 One study contributed to two assessment categories.11
Pulse assessment (n=10)
All studies included are observational. Four studies (2 in adults and 2 in children) included blinded clinicians who palpated pulses in patients on Extracorporeal Membrane Oxygenation (ECMO) or cardiac bypass (with the option of pulsatile or non-pulsatile flow).5-8 One study included nurses palpating pulses on anaesthetized children.13 Two more recent studies examined ultrasound-based carotid pulse assessment using recordings from patients undergoing cardiopulmonary bypass or by assessing physicians’ interpretation of prerecorded carotid ultrasound clips obtained from patients in cardiac arrest.14,15 The three simulation studies focused on pulse assessment in manikins.10-12
Diagnostic accuracy of pulse assessment varied among studies: 56.0%-89.0% for adult patients on ECMO,6 78.0% for pediatric patients on ECMO,7,8 78.9%-94% for adult manikin studies.10,11 One simulation study reported significantly lower accuracy when participants were given <10 seconds to perform the pulse assessment compared with unlimited time (38.0% and 83.8%).12
Two studies reported higher accuracy in identifying pulse presence than pulse absence (pediatric ECMO: 50.3% vs 27.5%;7 adult manikin: 55.3% vs 18.3%).12 Whereas a third study reported slightly higher accuracy for pulse absence (77.0%) than pulse presence (74.0%) in an adult manikin.10 In two pediatric ECMO studies, pulse assessment accuracy was higher among physicians than nurses (80%–83% vs 73%–75%).7,8 Time to pulse assessment decision varied across studies, partly reflecting differences in outcome definitions. Median times ranged from 2 to 3 minutes in an adult ECMO study, 6 while mean times ranged from 7 seconds in an adult manikin study10 to 20 seconds in a pediatric ECMO study.7
Breathing assessment (n=3)
One randomised controlled trial (RCT) compared standard CPR instruction with instruction supplemented by a slide and video explaining agonal breathing among medical students.17 Students receiving the additional instruction demonstrated greater accuracy in differentiating normal, agonal and absent breathing in a simulated assessment using a healthy adult volunteer (90% vs 78%, p=0.03). They were also more likely to identify agonal breathing in an unconscious patient as an indication of cardiac arrest requiring CPR (75% vs 43%, p=0.01), recognise cardiac arrest and the need for CPR (sensitivity 90% vs 78%, p=0.02), and select the appropriate intervention (CPR vs recovery position; 90% vs 78%, p=0.03). Across both groups, decision times were slightly longer for agonal breathing (12.4 seconds) than for normal (10.6 seconds, p = 0.01) or absent breathing (10.5 seconds, p = 0.04). However, treatment decision times did not differ significantly between the intervention and control groups.17
One simulation study using video clips of a healthy volunteer simulating normal, abnormal and absent breathing reported an overall diagnostic accuracy of 72.0% among medical students.16 Diagnostic accuracy was highest for agonal gasping with airway obstruction (94%) and absent breathing (86%), but lowest for shallow (abnormal) breathing (23%). The proportion selecting the correct treatment (rescue breathing or recovery position) was highest for rapid (abnormal) breathing (98.0%) and agonal gasping without airway obstruction (92%), and lowest for agonal gasping with airway obstruction (55.0%) and shallow (abnormal) breathing (54%).
Finally, an adult manikin study found that breathing assessment accuracy was higher when breathing and pulse were assessed sequentially (10 seconds each) rather than simultaneously (10 seconds total) (88.0% vs 79.9%).11
Cardiac arrest rhythm assessment (n=8)
Eight studies examined cardiac arrest rhythm recognition, including three adult18,20,24 and three pediatric21,22,25 manikin studies, and two studies of ECG interpretation.19,23
In adult manikin studies, diagnostic accuracy was 91.0% for ventricular fibrillation (VF),24 91.4% for distinguishing shockable from non-shockable rhythms, 88.6% for non-shockable rhythms, and 95.2% for shockable rhythms.20 Physicians with previous CPR experience demonstrated higher rhythm interpretation accuracy than those without experience (81.0% vs 64.0%, p < 0.01).20 In a VF simulation, 86.0% of nurses assessed the pulse or level of consciousness before initiating CPR.24
In one ECG interpretation study, 95% of medical students correctly identified isolated VF, but only 2.5% (n = 1) recognised VF with pacing artefacts.23 In a computer-based ECG interpretation study involving prehospital emergency physicians, median sensitivity for identifying shockable rhythms requiring defibrillation was 91%, and median specificity for correctly identifying non-shockable rhythms was 91%.19 Rhythm-specific sensitivities were 100% for ventricular tachycardia and coarse ventricular fibrillation, but 60.0% for fine ventricular fibrillation. Specificities were 93% for asystole and 83% for pulseless electrical activity (PEA).19
2101Time to rhythm recognition and resuscitation decisions varied substantially across manikin studies. In adult manikin studies, mean rhythm decision times among physicians were 4.0 seconds overall, with shorter times for shockable than non-shockable rhythms (3.4 vs 4.4 seconds, p< 0.05).20 Among nurses, mean times to calling a Code Blue and initiating chest compressions were 12.0 and 28.8 seconds, respectively.24 In the ECG interpretation study, median decision times were 2.0 seconds for VT, 2.1 seconds for coarse VF, 2.4 seconds for asystole, and 2.8 seconds for PEA and fine VF.19
Two pediatric manikin studies examined responses to pulseless ventricular tachycardia (pVT)21,22 and one examined responses to VF.25 In a pVT study, 93.0% of pediatric residents recognised apnoea as an indication for assisted ventilation. However, 66.0% did not initiate chest compressions within 1 minute, 33.0% did not initiate chest compressions at all, and only 54.0% performed defibrillation within 3 minutes of pVT onset.22 In this study, median time to initiate assisted ventilation for apnoea was 24.5 seconds; median time to commence chest compressions ranged from 157 to 540 seconds according to experience; and median time to defibrillation was 170 seconds.22 In the other pVT study by the same authors, 62% of medical residents verbally identified the absence of a pulse during initial assessment, 13% assessed the pulse without verbal confirmation, and 25% focused on cardiac rhythm without assessing the pulse.21 In this study, residents who used an action-linked phrase connecting recognition of pulselessness with the instruction to commence compressions were more likely to initiate compressions (100% vs 58%, p = 0.002) and, among those who initiated compressions, did so sooner (median 30 vs 150 seconds, p < 0.001). In the pediatric VF simulation involving anaesthesia residents, mean times to recognising VF, initiating chest compressions, and requesting defibrillation were 76, 77, and 108 seconds, respectively.25
Influence of specific training and clinical experience
In a manikin RCT involving senior-year nursing students, animation-based education significantly reduced the median time to the initial resuscitation response compared with standard training (7.6 vs 42.7 seconds, p < 0.0001).18 The assessed actions included calling a Code Blue, lowering the head of the bed and initiating chest compressions without a pulse check.
In an adult manikin study, older age (ρ = −0.44, p < 0.05) and greater clinical experience (ρ = −0.49, p < 0.05) among nurses were associated with shorter delays in calling for help, whereas higher educational attainment was associated with longer delays (ρ = 0.63, p < 0.01).24 Physicians with previous CPR experience also made defibrillation decisions significantly faster than those without experience (mean 3.5 vs 4.9 seconds, p < 0.0001).20 In a pediatric manikin study, more experienced residents initiated chest compressions sooner than less experienced residents (median time: Year 1, 540 seconds; Year 2, 210 seconds; Year 3, 157 seconds), although the difference was not statistically significant (p = 0.30).22
3. Narrative Reporting of the task force discussions
The Task Forces noted that no included studies evaluated healthcare professionals recognizing cardiac arrest in real time in patients experiencing an actual cardiac arrest. Although one study used prerecorded carotid ultrasound clips obtained from patients in cardiac arrest, clinicians did not assess these patients directly. Most studies involved manikins, patients receiving extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass, or healthy volunteers. This represents an important gap in the evidence on real-time recognition of cardiac arrest in clinical practice. Task Force members highlighted the limitations of simulation studies in reproducing real-world clinical conditions and the inability of ECMO and cardiopulmonary bypass models to fully replicate the physiological and clinical characteristics of cardiac arrest. Consequently, caution is warranted when extrapolating these findings to inform clinical practice recommendations.
Of the ten studies examining pulse assessment, eight were conducted between 1996 and 2010. These earlier studies highlighted the limitations of pulse palpation in determining the presence or absence of cardiac arrest, informing the 2010 ILCOR recommendation against relying on pulse assessment as the sole indicator of cardiac arrest. However, the Task Forces acknowledged that conventional recognition criteria may be unreliable in certain clinical circumstances, such as in sedated, paralyzed or mechanically ventilated patients experiencing pulseless electrical activity (PEA), where assessment of responsiveness and breathing may not be feasible and arterial blood pressure or end-tidal carbon dioxide (ETCO₂) monitoring may be unavailable. The two more recent studies, published in 2020 and 2021, investigated the use of point-of-care ultrasound to assess carotid pulsatility, reflecting advances in technology and its increasing use in clinical assessment.
The considerable heterogeneity in study populations further limited the interpretation and comparability of findings. Participants included emergency medical technicians, paramedics, physicians, nurses and other healthcare professionals, with substantial variation in clinical experience, training and professional qualifications. These differences may have contributed to the observed variability in diagnostic accuracy and time to recognition.
Only two RCTs were identified, both evaluating targeted education for recognition. One examined the effect of additional education on recognising agonal breathing as an indicator of cardiac arrest, using simulated breathing patterns in healthy volunteers. The other evaluated animation-based education in a manikin scenario, focusing on recognising cardiac arrest and timely initiation of resuscitation. Although both demonstrated improvements in their respective outcomes, their findings were limited to simulated settings.
Overall, the available evidence demonstrated considerable variability in the accuracy and timeliness of cardiac arrest recognition by healthcare professionals. Diagnostic accuracy varied across studies and assessment modalities, and the available evidence was insufficient to establish the reliability of any individual assessment method for recognizing cardiac arrest in actual clinical settings. Furthermore, no studies specifically examined other potential clinical indicators of cardiac arrest, such as involuntary movements or seizure-like activity. The Task Forces considered the available new evidence insufficient to warrant a full systematic review. The 2010 treatment recommendations have been downgraded to good practice statements to acknowledge that they have not been reviewed using the Grading of Recommendations. Edits were performed to improve understanding and a new implementation consideration has been created for patients who cannot be assessed with responsiveness and breathing.
Good Practice Statements
Lay rescuers should use a rapid assessment of unresponsiveness and absent or abnormal breathing to identify cardiac arrest in adults and children (Good Practice Statement).
Healthcare professionals should use a rapid assessment of unresponsiveness and absent or abnormal breathing to identify cardiac arrest in adults and children when these clinical signs can be reliably assessed (Good Practice Statement).
- Implementation Consideration: In patients for whom responsiveness and breathing cannot be reliably assessed, such as sedated, paralysed or mechanically ventilated patients, healthcare professionals may need to use additional clinical assessments and physiological monitoring to identify cardiac arrest.
Healthcare professionals should not use pulse palpation as the sole determinant of cardiac arrest (Good Practice Statement).
- Implementation Consideration: Resuscitation training that addresses cardiac arrest recognition should include education on agonal gasping as abnormal breathing and a potential sign of cardiac arrest
Justification for the Good Practice Statements
The Task Forces considered that these Good Practice Statements meet the updated GRADE criteria because they reflect established principles of cardiac arrest recognition, are necessary to guide resuscitation practice, and have anticipated benefits that clearly outweigh potential harms. Prompt recognition of cardiac arrest is essential for timely initiation of CPR and defibrillation. These principles have been embedded in international resuscitation guidelines for many years and are unlikely to change with further evidence.
For lay rescuers, indirect evidence supporting these statements includes studies demonstrating the unreliability of pulse palpation, the challenges of recognising agonal breathing, and observational evidence associating early bystander CPR and defibrillation with improved survival. Together, these findings support the use of unresponsiveness and absent or abnormal breathing as practical indicators of cardiac arrest, enabling lay rescuers to initiate resuscitation promptly without additional assessments that may delay treatment.
The 2010 ILCOR Treatment Recommendation identified unresponsiveness and absent or abnormal breathing as the key indicators of cardiac arrest and advised against relying on pulse palpation alone. The current scoping review identified 20 studies examining recognition by healthcare professionals, including pulse assessment, breathing assessment and cardiac rhythm interpretation. Although no studies evaluated real-time recognition in patients experiencing actual cardiac arrest, the available evidence demonstrated substantial variability in the accuracy of individual assessment methods, particularly pulse palpation. Two randomised controlled trials demonstrated that targeted education could improve recognition of abnormal breathing or reduce delays in initiating resuscitation actions in simulated settings. These findings are consistent with the existing recommendations, although they do not establish the comparative effectiveness of different recognition strategies in clinical practice.
The Task Forces acknowledged that conventional recognition criteria may not be applicable in all clinical circumstances, particularly in sedated, paralysed or mechanically ventilated patients, where additional clinical assessment and physiological monitoring may be necessary. However, this does not alter the fundamental principle that cardiac arrest should be recognised promptly and that pulse palpation should not be relied upon as the sole determinant.
The Task Forces considered that the proposed statements are clear, actionable and grounded in established essential clinical principles and practices, supported by longstanding indirect scientific evidence. Deliberately withholding rapid assessment of responsiveness and breathing when these can be reliably assessed, or relying exclusively on pulse palpation to identify cardiac arrest, would be inappropriate approaches to resuscitation. The anticipated benefits therefore clearly outweigh potential undesirable consequences. A formal systematic review specifically evaluating these fundamental practices was considered unlikely to provide information that would change the recommendations. Accordingly, the Task Forces considered Good Practice Statements appropriate, while recognising that further research is needed to determine optimal methods and sequencing of cardiac arrest assessment in different clinical settings.
Knowledge Gaps
The Task Forces identified the following gaps in the evidence:
- Real-time recognition of cardiac arrest: The accuracy and timeliness of cardiac arrest recognition by healthcare professionals directly assessing patients experiencing actual cardiac arrest in real time remain unknown.
- Assessment methods and sequencing: The comparative accuracy and timeliness of different cardiac arrest recognition methods, including the sequence of assessing responsiveness and breathing, have not been evaluated in patients experiencing actual cardiac arrest.
- Pulse assessment in specific clinical circumstances: The role and accuracy of pulse assessment remain uncertain in circumstances where conventional recognition criteria may be unreliable, such as in sedated, paralysed or mechanically ventilated patients experiencing pulseless electrical activity (PEA), particularly when arterial blood pressure or end-tidal carbon dioxide (ETCO₂) monitoring is unavailable.
Evidence to Decision (EtD) Table
BLS 2101 Evidence to Decision Table Et D October2026
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