What are the latest 2025 updates on Advanced Cardiovascular Life Support (ACLS) guidelines?

2025 ACLS Updates: Key Changes and Recommendations

The 2025 American Heart Association ACLS guidelines introduce several critical updates, most notably the formal integration of extracorporeal CPR for refractory cardiac arrest, refined temperature management protocols, and elimination of routine calcium administration during cardiac arrest. 1, 2

Major Changes from Previous Guidelines

Vasopressor Management

• Epinephrine remains the primary vasopressor at 1 mg IV/IO every 3-5 minutes throughout cardiac arrest. 3, 4
• For nonshockable rhythms (asystole/PEA), administer epinephrine as soon as feasible after confirming cardiac arrest. 3, 4
• For shockable rhythms (VF/pVT), give epinephrine after initial defibrillation attempts have failed, typically after the second or third shock. 3, 4
• High-dose epinephrine is NOT recommended for routine use—standard 1 mg dosing only. 4
• Vasopressin alone or in combination with methylprednisolone offers no advantage over epinephrine and is not recommended as a substitute. 3

Calcium Administration - Major Change

• Routine calcium administration during cardiac arrest is NO LONGER recommended. 3, 4, 5 This represents a significant departure from previous practice patterns where calcium was sometimes given empirically.

Extracorporeal CPR (ECPR) - New Recommendation

• 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. 3, 4, 5
• The process should be initiated early in patients not responding to conventional therapies, as implementation takes time. 3
• This applies to carefully selected patients in centers with established ECPR programs and protocols. 2

Post-Cardiac Arrest Temperature Management - Updated Protocol

• ALL adults who do not follow commands after ROSC must receive deliberate temperature control, regardless of arrest location or presenting rhythm. 3, 4
• Select and maintain a constant temperature between 32°C and 37.5°C during the post-arrest period. 3, 4, 5
• Patients with spontaneous hypothermia after ROSC should NOT be rewarmed faster than 0.5°C per hour. 3, 4, 5
• There is insufficient evidence to recommend specific therapeutic temperatures for different patient subgroups—the key is selecting a target and maintaining it consistently. 3

Coronary Angiography Strategy - Selective Approach

• Emergency coronary angiography is NOT recommended over a delayed or selective strategy unless patients exhibit specific high-risk features after ROSC. 3, 4
• Perform emergency angiography ONLY if patients have:
  • ST-segment elevation MI on ECG
  • Cardiogenic shock
  • Electrical instability (recurrent arrhythmias)
  • Signs of significant myocardial damage
  • Ongoing ischemia 3, 4

Seizure Management - New Guidance

• A therapeutic trial of nonsedating antiseizure medication may be reasonable in adult cardiac arrest survivors with EEG patterns on the ictal-interictal continuum. 3, 4, 5
• This represents new recognition of the importance of treating subclinical seizure activity in post-arrest patients. 2

CPR Quality Emphasis - Reinforced Standards

Chest Compression Parameters

• Depth: At least 2 inches (5 cm) but not exceeding 2.4 inches (6 cm) 4, 6, 5
• Rate: 100-120 compressions per minute 4, 6, 5
• Allow complete chest recoil after each compression—do not lean on the chest. 4, 6
• Minimize interruptions in chest compressions to less than 10 seconds. 4, 6
• Rotate compressors every 2 minutes to prevent fatigue and maintain compression quality. 4

CPR Quality Monitoring

• Use quantitative waveform capnography with target PETCO2 >10 mmHg to monitor CPR quality. 4
• Arterial pressure monitoring can also be used when available to assess perfusion during CPR. 4
• Higher arterial PO2 during CPR has been associated with increased hospital admission rates. 4

Defibrillation Protocol

Shock Strategy

• Single-shock strategy is recommended (not stacked shocks) for VF/pVT. 4, 5
• Biphasic dose: 120-200 joules for first shock 5
• Monophasic dose: 360 joules 5
• Resume CPR immediately for 2 minutes after shock delivery before rhythm reassessment. 5

Antiarrhythmic Medications for Refractory VF/pVT

• Consider amiodarone OR lidocaine for shock-refractory VF/pVT after 2-3 failed defibrillation attempts. 3, 4, 6, 5
• Amiodarone dosing: 300 mg IV/IO bolus for first dose, then 150 mg for second dose 4, 5
• Lidocaine dosing: 1-1.5 mg/kg IV/IO for first dose, then 0.5-0.75 mg/kg for second dose 4, 5
• Studies support early administration of antiarrhythmics, as survival decreases with longer times to drug administration. 3
• Magnesium is NOT recommended for routine use in shock-refractory VF/pVT. 3

Advanced Airway Management

Ventilation Strategy

• Provide 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions once an advanced airway is placed. 4, 6, 5
• Before advanced airway placement, use 30:2 compression-to-ventilation ratio for healthcare providers. 6, 5
• Avoid excessive ventilation, which can be detrimental to outcomes. 4

Airway Confirmation

• Use waveform capnography to confirm and continuously monitor advanced airway placement. 4, 5
• Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved. 7

Oxygen Administration

• Use maximal inspired oxygen concentration during CPR. 4
• Implement a deliberate oxygenation strategy as part of post-cardiac arrest care, targeting oxygen saturation 92-98%. 4, 5

Special Populations and Circumstances

Pediatric Cardiac Arrest

• Compression depth: At least one-third anteroposterior diameter of chest 5
• Compression-to-ventilation ratio: 30:2 for single rescuers, 15:2 for two healthcare providers 5
• Epinephrine dosing: 0.01 mg/kg IV/IO every 3-5 minutes (maximum single dose 1 mg) 5
• Amiodarone dosing: 5 mg/kg IV/IO bolus for refractory VF/pVT 5

Pregnant Patients

• Perform lateral uterine displacement to relieve aortocaval compression during resuscitation. 4

Toxicology-Related Cardiac Arrest

• High-dose insulin therapy is recommended early for life-threatening β-blocker and calcium channel blocker poisoning. 3
• Sodium bicarbonate should be added to standard ACLS for dysrhythmias from cocaine or sodium channel blockers. 3
• For suspected cyanide poisoning, treat immediately with hydroxocobalamin without waiting for confirmatory testing. 3
• 20% intravenous lipid emulsion is efficacious for life-threatening local anesthetic toxicity, especially bupivacaine. 3

Post-Resuscitation Care Algorithm

Hemodynamic Management

• Maintain mean arterial pressure ≥65 mmHg using vasopressors as needed. 5
• Obtain 12-lead ECG immediately after ROSC to guide further management. 5

Neurological Care

• Implement targeted temperature management between 32°C-37.5°C for all patients not following commands. 5
• Consider antiseizure medication for patients with concerning EEG patterns. 5

Systems of Care Considerations

Organ Donation

• Organ donation is now formally recognized as an important outcome to consider in the development and evaluation of cardiac arrest systems of care. 3, 4, 5
• This represents acknowledgment that even when resuscitation is unsuccessful, organ donation can provide meaningful benefit. 3

Diversity, Equity, and Inclusion

• The 2025 guidelines emphasize the importance of developing methods to improve representation of participants from diverse backgrounds in cardiac arrest research. 3
• Improved accuracy in reporting study subject demographics is essential for understanding disparities in outcomes. 3

Critical Pitfalls to Avoid

Recognition and Response Errors

• Do NOT delay chest compressions to check for pulse in suspected cardiac arrest—if in doubt, start CPR. 4, 6
• Do NOT misinterpret agonal gasping as normal breathing—gasping indicates cardiac arrest. 4, 6
• Do NOT interrupt chest compressions unnecessarily during resuscitation, including during advanced airway placement. 4, 6

Medication Errors

• Do NOT administer calcium routinely during cardiac arrest. 4, 6
• Do NOT use high-dose epinephrine routinely—stick to standard 1 mg dosing. 4

Post-Resuscitation Errors

• Do NOT perform emergency coronary angiography for all post-ROSC patients regardless of presentation—use selective criteria. 4, 6
• Do NOT rewarm hypothermic post-arrest patients faster than 0.5°C per hour. 4

Mechanical CPR Devices

• Automated mechanical chest compression devices are NOT recommended for routine use but are reasonable alternatives when sustained high-quality manual compressions are impractical or compromise provider safety. 3