What is the current adult cardiopulmonary resuscitation (CPR) protocol according to the 2025 American Heart Association Guidelines and the 2023 focused update on Advanced Cardiovascular Life Support?

Current Adult CPR Protocol

The 2025 American Heart Association Guidelines maintain the C-A-B sequence (Chest compressions-Airway-Breathing) with immediate high-quality chest compressions as the cornerstone of resuscitation, emphasizing compression depth of at least 2 inches (5 cm), rate of 100-120 per minute, and minimal interruptions. 1, 2

Initial Assessment and Activation

• Check for responsiveness by shouting at the patient and tapping their shoulders 1
• Simultaneously assess breathing and pulse within 10 seconds—look for absent or only gasping respirations while checking for a definite pulse 1
• Immediately shout for nearby help and activate the emergency response system via mobile device if appropriate 1, 2
• Send someone to retrieve an AED and emergency equipment as soon as possible 1

High-Quality CPR Technique

Chest Compressions:

• Push hard and fast: at least 2 inches (5 cm) depth at a rate of 100-120 compressions per minute 1, 3
• Allow complete chest recoil between compressions to maximize cardiac filling 1
• Minimize interruptions in chest compressions—keep pauses to less than 10 seconds 1, 3, 4
• Change compressors every 2 minutes or sooner if fatigued to maintain compression quality 1, 3

Compression-to-Ventilation Ratio:

• Perform cycles of 30 compressions followed by 2 breaths for all adult cardiac arrests 1, 2
• Avoid excessive ventilation which increases intrathoracic pressure and decreases cardiac output 1, 5

Defibrillation Protocol

AED Use:

• Apply the AED as soon as it becomes available without delaying chest compressions 1, 2
• Deliver one shock when prompted by the AED for shockable rhythms (VF/pulseless VT) 1
• Immediately resume CPR starting with chest compressions after shock delivery—do not check pulse or rhythm 1, 3
• Continue CPR for 2 full minutes until the AED prompts the next rhythm check 1, 3

Shock Energy:

• Biphasic defibrillators: 120-200 Joules initially (follow manufacturer recommendations); use maximum available if unknown 1
• Subsequent doses should be equivalent or higher 1

Rhythm and Pulse Check Protocol

Critical Timing:

• Check rhythm every 2 minutes during CPR cycles—never interrupt compressions for frequent checks 1, 3
• Only check pulse if an organized rhythm appears during the 2-minute rhythm assessment 3
• If any doubt exists about pulse presence, immediately resume chest compressions 3
• Keep all rhythm checks to less than 10 seconds to minimize interruption in perfusion 3

Advanced Life Support Interventions

Medication Administration:

• Establish IV or IO access for drug delivery—attempt IV first, use IO if IV unsuccessful 4, 5
• Administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms 1, 3, 5
• For refractory VF/pulseless VT, give amiodarone (first dose 300 mg bolus, second dose 150 mg) or lidocaine (first dose 1-1.5 mg/kg, second dose 0.5-0.75 mg/kg) 1, 3

Airway Management:

• Place an advanced airway (endotracheal tube or supraglottic device) when feasible 3, 5
• Confirm placement with waveform capnography 3, 5
• Once advanced airway is secured, provide 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions—no pauses for ventilation 1, 3, 5

Special Considerations for 2025 Updates

ECPR (Extracorporeal CPR):

• ECPR is reasonable for select patients with refractory cardiac arrest when provided within an appropriately trained and equipped system 1, 4
• The ARREST trial demonstrated significantly improved survival for patients with shockable rhythms receiving ECPR after prolonged resuscitation efforts 1

Medications NOT Recommended:

• Atropine is no longer recommended for routine use in pulseless electrical activity or asystole 1, 4
• Routine calcium administration is not recommended for undifferentiated cardiac arrest 4
• Sodium bicarbonate should not be routinely administered as it may worsen survival and neurological outcomes 1

Post-ROSC Care

Immediate Management:

• Confirm ROSC by checking pulse, blood pressure, or observing abrupt sustained increase in end-tidal CO2 5
• Target mean arterial pressure ≥65 mmHg with vasopressors as needed 3, 5
• Titrate oxygen to maintain saturation 94-98% to avoid both hypoxemia and hyperoxemia 4, 5
• Maintain normocapnia by adjusting ventilation parameters 5

Temperature Management:

• Initiate targeted temperature management for all patients who do not follow commands after ROSC 4, 5
• Maintain constant temperature between 32°C and 37.5°C 4

Coronary Intervention:

• Perform emergent coronary angiography for all cardiac arrest patients with ST-elevation on ECG 1
• Consider emergent angiography for selected patients without ST-elevation but with elevated risk of coronary disease, shock, or electrical instability 1

Common Pitfalls to Avoid

• Never check pulse immediately after shock delivery—this wastes critical time when compressions should resume 1, 3
• Do not perform frequent rhythm checks—each interruption decreases coronary perfusion pressure 3
• Avoid hyperventilation—excessive ventilation decreases cardiac output and cerebral blood flow 1, 5
• Do not use high-dose epinephrine—it provides no benefit over standard dosing 5
• Double sequential defibrillation has not been established as effective for refractory rhythms 4