What are the key changes in the 2025 Advanced Cardiovascular Life Support (ACLS) update for cardiac arrest management?

2025 ACLS Update: Key Changes in Advanced Cardiovascular Life Support

The most significant change in the 2025 ACLS guidelines is the formal discontinuation of routine calcium administration during cardiac arrest, alongside expanded recommendations for extracorporeal CPR (ECPR) in select refractory cases and mandatory targeted temperature management for all post-arrest patients who don't follow commands. 1, 2

Major Medication Changes

Calcium Administration - No Longer Routine

• Routine calcium administration for cardiac arrest treatment is now explicitly NOT recommended 1, 2, 3
• This represents a departure from previous practice where calcium was sometimes used empirically
• Calcium should only be considered for specific indications (hyperkalemia, hypocalcemia, calcium channel blocker toxicity) 1

Atropine Discontinued for PEA/Asystole

• Atropine is no longer recommended for pulseless electrical activity (PEA) or asystole 3, 4
• This simplifies the medication algorithm during non-shockable rhythms
• Focus remains on high-quality CPR and epinephrine administration 3

Epinephrine Dosing Remains Standard

• Epinephrine 1 mg IV/IO every 3-5 minutes remains the primary vasopressor 2
• For non-shockable rhythms: administer as soon as feasible 2
• For shockable rhythms: administer after initial defibrillation attempts fail 2
• High-dose epinephrine is NOT recommended for routine use 2

Advanced Resuscitation Techniques

Extracorporeal CPR (ECPR) - Now Reasonable

• 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, 3, 4
• This is a Class 2a recommendation, representing stronger support than previous guidelines 1
• Critical caveat: requires specialized teams, equipment, and protocols - not for general implementation 1
• Implementation takes time, so the process should be initiated early when considering ECPR 1

Double Sequential Defibrillation - Not Established

• Double sequential defibrillation for refractory shockable rhythms has NOT been established as effective (Class 2b, LOE C-LD) 3, 4
• Standard single-shock strategy remains preferred 2
• Amiodarone (300 mg first dose, 150 mg second dose) or lidocaine (1-1.5 mg/kg first dose, 0.5-0.75 mg/kg second dose) for refractory VF/pVT 2

Post-Cardiac Arrest Care - Major Updates

Targeted Temperature Management - Now Mandatory

• ALL adults who do not follow commands after return of spontaneous circulation (ROSC) must receive deliberate temperature control, regardless of arrest location or presenting rhythm 1, 3, 4
• This is a stronger, more universal recommendation than previous guidelines 1

Specific Temperature Targets

• Maintain a constant temperature between 32°C and 37.5°C 1, 3, 4
• Select one temperature within this range and maintain it consistently 1
• There is insufficient evidence to recommend specific temperatures for different patient subgroups 1, 4

Rewarming Rate Restrictions

• Patients with spontaneous hypothermia after ROSC who don't follow commands should NOT be rewarmed faster than 0.5°C per hour 1, 3, 4
• This prevents potential harm from rapid rewarming 1

Oxygenation Strategy

• Use 100% inspired oxygen during CPR 2, 3
• After ROSC, use 100% oxygen until arterial saturation can be reliably measured 3, 4
• Then target oxygen saturation 94-98% or PaO₂ 75-100 mmHg 3, 4
• Avoid both hypoxemia AND hyperoxemia 3, 4

Coronary Angiography - Selective Approach

• Emergency coronary angiography is NOT recommended over delayed/selective strategy in post-ROSC patients UNLESS they exhibit: 1, 2, 4
  • ST-segment elevation myocardial infarction
  • Cardiogenic shock
  • Electrical instability
  • Signs of significant myocardial damage
  • Ongoing ischemia
• This represents a more conservative, evidence-based approach than routine early catheterization 1

Seizure Management

• A therapeutic trial of a nonsedating antiseizure medication may be reasonable for adult survivors with EEG patterns on the ictal-interictal continuum 1, 2, 3, 4
• This is a new recommendation addressing post-arrest seizure-like activity 1
• Emphasizes nonsedating agents to avoid confounding neurological assessment 1

CPR Quality Emphasis - Unchanged but Reinforced

Core Metrics

• Compression depth: at least 2 inches (5-6 cm) 2, 3, 4
• Compression rate: 100-120 per minute 2, 3, 4
• Allow complete chest recoil between compressions 2, 4
• Minimize interruptions in compressions 2, 3
• Rotate compressors every 2 minutes to prevent fatigue 2, 3

Monitoring CPR Quality

• Use quantitative waveform capnography (target PETCO₂ >10 mmHg) 2
• Consider arterial pressure monitoring when available 2
• Real-time CPR feedback devices show positive effects on compression depth 3, 4

Advanced Airway Management

• Provide 1 breath every 6 seconds (10 breaths/min) with continuous compressions once advanced airway placed 2
• Use waveform capnography to confirm and monitor airway placement 2
• Avoid excessive ventilation - detrimental to outcomes 2

Vascular Access Priority

• IV access should be established first when possible 3, 4
• IO access considered only if IV attempts unsuccessful (Class 2a, LOE B-NR) 3, 4
• This clarifies the preferred sequence for vascular access 3

Systems of Care Considerations

Organ Donation Recognition

• Organ donation is now formally recognized as an important outcome to consider in systems of care development 2, 4
• Cardiac arrest patients represent an important pool of potential organ donors 1

Diversity and Equity

• Guidelines acknowledge lack of data limiting evaluation of diversity, equity, and inclusion in cardiac arrest populations 1, 4
• Call for improved representation of diverse participants in future research 1, 4

Special Circumstances

Cardiac Arrest in Pregnancy

• Perform lateral uterine displacement to relieve aortocaval compression 2
• Standard ACLS algorithms apply with pregnancy-specific modifications 1

Opioid-Associated Emergencies

• High-quality CPR should be the focus of initial care 3, 4
• Naloxone administered along with standard care only if it doesn't delay CPR components 3, 4

Drowning

• Emphasize rescue breathing along with compressions due to hypoxic nature 3, 4
• In-water rescue breathing by trained rescuers may prevent progression to cardiac arrest 3, 4

Common Pitfalls to Avoid

• Do NOT delay chest compressions to check for pulse - start compressions if cardiac arrest suspected 2
• Do NOT interrupt compressions unnecessarily during resuscitation 2
• Do NOT fail to recognize cardiac arrest due to misinterpreting gasping as normal breathing 2
• Do NOT administer calcium routinely during cardiac arrest 2, 4
• Do NOT perform emergency coronary angiography for all post-ROSC patients regardless of presentation 2, 4
• Do NOT rewarm hypothermic post-arrest patients faster than 0.5°C per hour 1, 3

Technology and Training Updates

Public Access Defibrillation

• PAD programs strongly recommended, particularly in aquatic environments and large public areas 3, 4
• Drone-delivered AEDs emerging as feasible technology with potential time gains 3

Educational Approaches

• Gamified learning shows promise for improving CPR performance and knowledge retention 3, 4
• Rapid cycle deliberate practice recommended for resuscitation training 1
• Real-time feedback devices improve compression quality metrics 3, 4