Latest Changes in CPR Guidelines 2025
The 2025 American Heart Association Guidelines maintain core CPR principles while emphasizing high-quality compressions at 100-120/min and 5-6 cm depth, with new focus on extracorporeal CPR for refractory arrests, refined post-resuscitation oxygen and temperature targets, and elimination of routine atropine use. 1, 2, 3
Core CPR Quality Metrics (Unchanged from Recent Updates)
The fundamental CPR technique remains consistent with recent guidelines:
- Compression depth: 5-6 cm for adults, avoiding excessive depth 1, 2
- Compression rate: 100-120 compressions per minute 4, 1, 2
- Complete chest recoil between compressions to enable proper cardiac filling 1, 2
- Minimize interruptions to maximize perfusion and chest compression fraction 1, 2
- Change compressors every 2 minutes or sooner if fatigued 2
- 30:2 compression-to-ventilation ratio for standard CPR 2
These recommendations are strongly supported by international consensus, though research shows achieving both optimal rate and depth simultaneously remains challenging, with only 15% of compressions meeting both targets in observational studies 5.
Key 2025 Updates and Changes
Medication Administration Changes
Atropine is no longer recommended for routine use in pulseless electrical activity (PEA) and asystole. 1 This represents a significant departure from previous practice patterns.
Calcium administration is not recommended for routine cardiac arrest treatment in adults 1
IV access should be established first when possible for drug administration, with IO access considered only if IV attempts are unsuccessful (Class 2a, LOE B-NR) 1, 2
Advanced Resuscitation Techniques
Extracorporeal CPR (ECPR) 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 major advancement in recognizing ECPR as a viable option rather than experimental therapy.
Double sequential defibrillation for refractory shockable rhythms has not been established as effective (Class 2b, LOE C-LD) 1, 2, clarifying that this technique should not be routinely employed.
Post-Resuscitation Care Refinements
Targeted temperature management is now mandatory for all adults who don't follow commands after return of spontaneous circulation (ROSC), regardless of arrest location or presenting rhythm 1, 2
Temperature targets: Maintain constant temperature between 32°C and 37.5°C 1, 2. There is insufficient evidence to recommend specific temperatures for different subgroups 1
Spontaneous hypothermia management: Patients with spontaneous hypothermia after ROSC who don't follow commands should not be routinely rewarmed faster than 0.5°C per hour 1
Oxygen management after ROSC:
- Use 100% inspired oxygen until arterial oxygen saturation can be reliably measured 1
- Target oxygen saturation of 94-98% or PaO₂ of 75-100 mmHg once arterial values can be measured 1, 2
- Avoid both hypoxemia and hyperoxemia 1, 2
Carbon dioxide management: Avoid hypocapnia, though insufficient evidence exists to recommend for or against mild hypercapnia 1
Coronary angiography: Emergency coronary angiography is not recommended over 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
Neurological Care Updates
Antiseizure medication: A therapeutic trial of a nonsedating antiseizure medication may be reasonable in adult survivors with electroencephalography patterns on the ictal-interictal continuum 1
Special Circumstances
Drowning resuscitation continues to emphasize rescue breathing along with chest compressions due to the hypoxic nature of drowning-related cardiac arrest 1, 2. In-water rescue breathing by appropriately trained rescuers may prevent progression to cardiac arrest 1
Opioid-associated emergencies: High-quality CPR should be the focus of initial care, with naloxone administered along with standard care only if it doesn't delay CPR components 1, 2. After return of spontaneous breathing, patients should be observed in a healthcare setting until risk of recurrent opioid toxicity is low 1
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 (PAD) programs are strongly recommended for implementation, particularly in aquatic environments and large public areas 4, 1, 2
Drone-delivered AEDs are emerging as a feasible technology, with 17 computer/prediction models and 9 test flight studies showing potential time gains compared with standard EMS response 4
Technology and Training
Real-time CPR feedback devices show mixed but generally positive effects on CPR quality metrics, particularly for compression depth 1, 2
Gamified learning shows promise for improving CPR performance and knowledge retention for healthcare professionals and laypeople 1
Virtual reality and augmented reality technologies show mixed results, with some evidence of improved knowledge acquisition but equivocal results for skills outcomes 1
Important Caveats and Pitfalls
Compression rate-depth trade-off: Research demonstrates an inverse relationship between compression rate and depth, with compliance to recommended depth significantly decreasing as rate increases (40% compliance at <100/min vs. 18% at >100/min) 5. Rescuers should focus on achieving both targets simultaneously rather than prioritizing rate over depth.
Personal protective equipment (PPE) effects: While PPE use during CPR shows no significant overall effect on CPR quality metrics in meta-analysis, individual studies show trends toward decreased compression depth and increased rescuer fatigue 4. Current recommendations do not suggest shortening CPR cycles when wearing PPE 4.
Dispatcher recognition challenges: Dispatcher recognition of cardiac arrest remains a challenge, with ongoing efforts to optimize protocols 1. This highlights the continued importance of dispatcher training.
Diversity and equity gaps: The 2025 guidelines acknowledge the lack of data that limits evaluation of diversity, equity, and inclusion in cardiac arrest populations, calling for improved representation in research 1