2025 ACLS and PALS Algorithms

The most current ACLS and PALS algorithms are based on the 2020 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care, with focused updates published through 2024. While there is no distinct "2025" version, the 2023 and 2024 ILCOR Consensus on Science with Treatment Recommendations provide the most recent evidence-based updates to these algorithms 1.

Core ACLS Algorithms (Current Through 2024)

Adult Cardiac Arrest Algorithm

For VF/Pulseless VT:

Begin high-quality CPR immediately (rate 100-120/min, depth ≥2 inches) 2, 3
Deliver one shock as soon as defibrillator available (biphasic 120-200J per manufacturer; monophasic 360J) 2, 4
Resume CPR immediately for 2 minutes before rhythm reassessment 3, 4
Administer epinephrine 1 mg IV/IO every 3-5 minutes 1, 3
After 2-3 failed shocks, give amiodarone 300 mg IV/IO bolus (or lidocaine 1-1.5 mg/kg IV/IO as alternative) 2, 3
Second amiodarone dose: 150 mg IV/IO 2

For PEA/Asystole:

Begin high-quality CPR immediately 3
Administer epinephrine 1 mg IV/IO as soon as feasible, then every 3-5 minutes 1, 3
Search for and treat reversible causes (H's and T's) 3

Advanced Airway Management

Place endotracheal tube or supraglottic airway without interrupting compressions 3, 4
Confirm placement immediately with waveform capnography 2, 3, 4
After advanced airway: deliver 1 breath every 6 seconds (10 breaths/min) with continuous compressions 3, 4
Avoid excessive ventilation 2

Post-Cardiac Arrest Care Algorithm

Immediate Post-ROSC Management:

Maintain mean arterial pressure ≥65 mmHg using vasopressors 3
Target oxygen saturation 92-98% 3
Obtain 12-lead ECG immediately 3

Temperature Control (2023 Update):

All adults who do not follow commands after ROSC should receive treatment that includes a deliberate strategy for temperature control, regardless of arrest location or presenting rhythm 1
Select and maintain constant temperature between 32°C and 37.5°C 1
For spontaneous hypothermia after ROSC, do not actively or passively rewarm faster than 0.5°C per hour 1

Coronary Angiography (2023 Update):

Emergency coronary angiography is NOT recommended over delayed/selective strategy UNLESS patient exhibits ST-segment elevation MI, shock, electrical instability, signs of significant myocardial damage, or ongoing ischemia 1

Special Considerations

Extracorporeal CPR (2023 Update):

ECPR is reasonable for select patients with cardiac arrest refractory to standard ACLS when provided within appropriately trained and equipped system of care 1
Consider for witnessed arrests with shockable rhythms when conventional CPR is failing 4

Calcium Administration (2023 Update):

Routine administration of calcium for treatment of cardiac arrest is NOT recommended 1

Seizure Management (2023 Update):

A therapeutic trial of nonsedating antiseizure medication may be reasonable in adult survivors with EEG patterns on the ictal-interictal continuum 1

Core PALS Algorithms (Current Through 2024)

Pediatric Cardiac Arrest Algorithm

CPR Quality:

Compression depth: at least one-third anteroposterior diameter of chest 3
Rate: 100-120 compressions/min 3
Compression-ventilation ratio: 30:2 for single rescuer; 15:2 for two healthcare providers 1
Allow complete chest recoil 3
Minimize interruptions to <10 seconds 3

Medication Dosing:

Epinephrine: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 solution) every 3-5 minutes 1
Maximum single dose: 1 mg 1

Defibrillation:

Initial dose: 2 J/kg 1
Subsequent doses: 4 J/kg (maximum 10 J/kg or adult dose) 1
Use largest pads that fit on chest without touching 1

Antiarrhythmics for Refractory VF/pVT:

Amiodarone: 5 mg/kg IV/IO bolus (may repeat up to 2 additional doses for total of 15 mg/kg) 1
Lidocaine: 1 mg/kg IV/IO (if amiodarone unavailable) 1

Pediatric Bradycardia Algorithm

When to Start CPR:

Heart rate <60/min with signs of poor perfusion despite adequate oxygenation and ventilation 1

Medications:

Epinephrine: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000) every 3-5 minutes 1
Atropine: 0.02 mg/kg IV/IO (minimum 0.1 mg, maximum single dose 0.5 mg) 1

Pediatric Tachycardia Algorithm

Supraventricular Tachycardia:

Adenosine: First dose 0.1 mg/kg IV/IO rapid push (maximum 6 mg); second dose 0.2 mg/kg (maximum 12 mg) 1
Synchronized cardioversion: 0.5-1 J/kg; if ineffective, increase to 2 J/kg 1

Special Pediatric Populations

Single Ventricle/Fontan Circulation:

Specific resuscitation considerations for patients with stage I repair, hemi-Fontan/bidirectional Glenn, or Fontan circulation 1
Focus on maintaining adequate preload and avoiding excessive positive pressure ventilation 1

Septic Shock:

Aggressive fluid resuscitation and early vasopressor support 1

Key Updates from 2023-2024 ILCOR Reviews

Topics Reviewed by Systematic Reviews:

ACLS:

ECPR for cardiac arrest 1
Double sequential defibrillation for refractory shockable rhythm 1
Post-arrest oxygenation, ventilation, and hemodynamics 1
Post-arrest temperature control 1
Post-arrest seizure management 1
Prognostication using GCS motor score, imaging, biomarkers, EEG, and SSEPs 1

PALS:

ECPR for pediatric cardiac arrest 1
Prediction of survival with good neurological outcome using clinical examination, blood biomarkers, electrophysiology, and brain imaging 1

Topics Reviewed by Evidence Updates: