What are the updates to the 2025 American Heart Association (AHA) guidelines for Cardiopulmonary Resuscitation (CPR) and cardiac arrest management?

2025 AHA Recommendations for CPR and Cardiac Arrest: Key Updates

The 2025 American Heart Association (AHA) guidelines for CPR and cardiac arrest management include significant updates focusing on extracorporeal cardiopulmonary resuscitation, temperature management, coronary angiography, calcium administration, and seizure management. 1, 2

Core CPR Fundamentals (Reaffirmed)

• High-quality chest compressions remain the cornerstone of effective resuscitation, with a recommended depth of 5-6 cm and rate of 100-120 compressions per minute 2, 3
• Complete chest recoil between compressions is essential for proper cardiac filling 3
• Minimizing interruptions in chest compressions maximizes perfusion and improves outcomes 2, 3
• Compression-to-ventilation ratio remains 30:2 for standard CPR 3

Major New Recommendations

Medication Administration

• Routine administration of calcium for cardiac arrest treatment is not recommended 1
• IV access should be established first when possible for drug administration in cardiac arrest (Class 2a, LOE B-NR), with IO access considered if IV attempts are unsuccessful 1, 3

Extracorporeal CPR (ECPR)

• Use of extracorporeal cardiopulmonary resuscitation is now considered reasonable for select patients with cardiac arrest refractory to standard ACLS when provided within an appropriately trained and equipped system of care 1, 2
• This represents a significant advancement in the approach to refractory cardiac arrest 2

Post-Arrest Temperature Management

• All adults who do not follow commands after return of spontaneous circulation, regardless of arrest location or presenting rhythm, should receive treatment that includes a deliberate strategy for temperature control 1, 2
• A constant temperature between 32°C and 37.5°C should be selected and maintained during post-arrest temperature control 1, 3
• Patients with spontaneous hypothermia after ROSC who don't follow commands should not be routinely rewarmed faster than 0.5°C per hour 1

Coronary Angiography

• Emergency coronary angiography is not recommended over a delayed or selective strategy after ROSC unless patients exhibit ST-segment elevation MI, shock, electrical instability, signs of significant myocardial damage, or ongoing ischemia 1
• This represents a more selective approach to post-arrest coronary intervention 1

Seizure Management

• A therapeutic trial of a nonsedating antiseizure medication may be reasonable in adult survivors with electroencephalography patterns on the ictal-interictal continuum 1, 2
• This addresses the important issue of post-arrest seizure management 2

Special Circumstances Updates

Drowning Resuscitation

• For drowning victims, airway management and ventilation are particularly important due to the hypoxic nature of the arrest 2, 3
• In-water rescue breathing by appropriately trained rescuers may prevent progression to cardiac arrest 2

Opioid-Associated Emergencies

• CPR should be the focus of initial care for suspected opioid overdose 2, 3
• Naloxone can be administered along with standard care if it doesn't delay high-quality CPR 2, 3
• After return of spontaneous breathing following naloxone, patients should be observed until risk of recurrent opioid toxicity is low 2, 3

Systems of Care Improvements

• Organ donation is now recognized as an important outcome that should be considered in the development and evaluation of systems of care 1, 2
• Public-access defibrillation programs are recommended in aquatic environments and large public areas 2, 3
• Real-time CPR feedback devices show generally positive effects on CPR quality metrics 2

Diversity, Equity, and Inclusion

• The 2025 guidelines acknowledge the lack of data in recent cardiac arrest literature that limits evaluation of diversity, equity, and inclusion in this population 1
• There is a call for researchers to develop and implement methods to improve representation of participants from diverse backgrounds 1

Pitfalls and Caveats

• Double sequential defibrillation for refractory shockable rhythms has not been established as effective (Class 2b, LOE C-LD) 1, 3
• There is insufficient evidence to recommend a specific therapeutic temperature for different subgroups of cardiac arrest patients 1
• Avoid both hypoxemia and hyperoxemia after ROSC, targeting oxygen saturation of 94-98% once reliably measured 2, 3
• Avoid hypocapnia during post-ROSC care 2, 3