CPR 2025: Do International Guidelines Speak the Indian Reality?

Introduction Over time, the science of cardiopulmonary resuscitation (CPR) has progressively emerged with substantial evidence for many aspects required for making a stepwise approach to manage a cardiac arrested victim. In spite of these advancements, certain research questions related to CPR remain unanswered for various reasons, such as the feasibility of conducting research, patient population recruitment, etc. These unanswered aspects remain equally important to frame CPR guidelines, and hence, expert consensus remains the foundation for these aspects. The International Liaison Committee on Resuscitation (ILCOR) regularly updates its evidence synthesis and delineates CPR science.[1-3] Various resuscitation councils utilise these to establish their regional CPR guidelines. Various member resuscitation councils of ILCOR use this science to frame their own regional guidelines, with a focus on the systems of care in their respective regions. Nevertheless, this creates an important point of discussion: Are the global recommendations suitable for their applicability in the Indian population or needs to be tailored as per need? In view of geographical, demographical, and infrastructural diversity, such consensus varies across the globe based on the theory of population and geography. To quote an example, the site of chest compression shall vary with population variability with regards to height, physique and build. Hence, different CPR-related guidelines mark different sites and methods of their identification for performing chest compression. Moreover, the evidence synthesis may also be skewed because the included studies do not include a population representative of the global population. Hence, the conclusion remains skewed towards the demography and geography of the population included. In this regard, the guidelines of the Indian Resuscitation Council Federation (IRCF) remain of paramount importance owing to their optimal applicability within Indian circumstances.[4-7] Science is Global—But Context and Application are Local The 2025 ILCOR consensus continues to be based on a structured assessment of evidence through systematic reviews and treatment recommendations. ILCOR provided science is customised into regional guidelines by different resuscitation councils. Nonetheless, it is important to recognise that guidelines are frameworks requiring local adaptation, influenced by legislation, healthcare systems, and demographic and geographical factors. This consideration is integral to the ongoing discussion for focused and suitable frameworks for the CPR guidelines. Why Regional Differences Exist: Beyond Physiology Despite biological universality, the aetiology of cardiac arrest and its management are influenced by many system variables, and not just science.[8-10] Let us have a look at some of these variables, which can help the policy makers and scientists in framing tailor-made CPR guidelines. Epidemiological divergence Epidemiological variation in cardiac arrest is observed across geographical regions. The aetiology of cardiac arrest does not fit neatly into the traditional “5 Hs and 5 Ts” framework and may require the additional “HIT THE TARGET” approach of IRCF, incorporating hypo-/hyperglycaemia and raised intracranial tension as reversible causes of cardiac arrest, to guide appropriate management strategies for cardiac arrest victims. Such variation affects the relative importance of ventilation versus compression-only CPR, especially in paediatric and asphyxial The aetiology of cardiac arrest does not fit neatly into the traditional “5 Hs and 5 Ts” framework and may require the additional “HIT THE TARGET” approach,[7] incorporating hypo-/hyperglycaemia and raised intracranial tension as reversible causes of cardiac arrest, to guide appropriate management strategies for cardiac arrest victims. arrests, areas where even ILCOR acknowledges existing variability. Prehospital care deficit The status of Emergency Medical Services across the globe varies with regard to its availability, penetration, timeliness, policies, etc. The availability and training for the effective use of automated external defibrillators are also limited and differ across regions. The CPR guidelines from various professional bodies and resuscitation councils promote effective and optimal pre-hospital care. Any weakness here affects the whole chain of survival or the optimal outcome of a cardiac-arrested victim. Sociocultural barriers Reluctance to provide early CPR stems from gender bias and legal fears, despite the presence of Good Samaritan protections. Low awareness and training in CPR among laypersons remains another important cause of fewer CPR attempts by laypersons. The ILCOR literature also raises concerns about providing timely and effective CPR, given societal perceptions and gender biases. Health system heterogeneity Health care delivery in India is highly variable, ranging from tertiary urban intensive care units to resource-limited rural centres. Health is primarily a state responsibility, and thus, guidelines that assume uniform access remain difficult to implement effectively. These challenges are not merely administrative; they directly affect training, dissemination, adoption, and outcomes of resuscitation systems. The Indian Response: IRCF and Contextualisation To address these gaps, the IRCF launched compression-only life support (COLS) for laypeople, as well as basic cardiopulmonary life support (BCLS) and comprehensive cardiopulmonary life support (CCLS), designed for the Indian population and suitable for healthcare settings. These approaches emphasise simplicity, practicality, and rapid dissemination. Notably, COLS addresses a major Indian obstacle: bystander reluctance to perform mouth-to-mouth breathing. It promotes early intervention by emphasising chest-compression-only resuscitation, which is easy to teach to laypeople. Evidence from India: The Missing Link A recurring limitation is that global guidelines mainly rely on data from Western registries, like Out-of-Hospital Cardiac Arrest registries in North America, Europe, and Japan. India faces obstacles, such as lacking large, standardised cardiac arrest registries and infrequent reporting with Utstein templates [Table 1].Table 1: Cardiopulmonary resuscitation international guidelines and IndiaThese obstacles have been addressed effectively in recent years in India through efforts by various professional bodies and support and initiatives from the government as well. The impact of “Make In India” is positive and appears to be a remarkable improvement in various aspects of care for cardiac arrest victims. It shall lead the way more proactively in the coming times. The Way Forward: Toward “Global” Resuscitation Science India requires its own guidelines rather than relying solely on international ones. The initiative taken by IRCF is primarily to use evidence tailored to local needs. Further strengthening it with evidence generated through research, cardiac arrest registries, and implementing Utstein-style reporting.[11] IRCF guidelines are well-framed and tiered to be suitable across the population and health care workers. COLS for laypeople and BCLS/CCLS (basic and advanced CPR) for healthcare providers across settings. Furthermore, to strengthen the prehospital care initiative of CPR training in schools, mass awareness campaigns, and inclusion in national health policies are important. Conclusion While scientific bodies like ILCOR provide CPR science based on available evidence, resuscitation councils worldwide use this evidence to develop their own alternate resuscitation model and guidelines. Indian with its different demographical, geographical, cultural and epidemiological profiles, along with healthcare and linguistic diversity, adapting the guidelines from different non-Indian resuscitation councils to the local context is crucial. The future isn’t about choosing between international and local guidelines but about combining both, creating a truly “global” resuscitation approach where Indian guidelines are based on global science and tailored to Indian realities. The IRCF initiative is a vital step toward achieving this integration. Acknowledgment None. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Disclosure of use of artificial intelligence (AI)-assistive or generative tools The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and formatting.