What are the key recommendations and changes in the 2026 Advanced Cardiovascular Life Support (ACLS) update?

ACLS 2026 Update Summary

The most current ACLS guidelines are the 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, which continue to emphasize high-quality CPR as the foundation of all resuscitation efforts, with updated recommendations on compression quality, early defibrillation, and integrated post-cardiac arrest care. 1

Core CPR Quality Standards

High-quality chest compressions remain the cornerstone of successful resuscitation, with specific metrics that must be achieved consistently throughout the resuscitation effort. 2

• Compress at a depth of at least 5 cm (approximately 2 inches) at a rate of 100-120 compressions per minute 3, 2
• Allow complete chest recoil after each compression to maximize coronary perfusion 2
• Minimize all interruptions to less than 10 seconds, including pauses for rhythm checks, defibrillation, or pulse assessment 2
• Rotate the compressor every 2 minutes or sooner if fatigue develops 3, 2
• Use a compression-to-ventilation ratio of 30:2 when no advanced airway is in place 3, 2
• Once an advanced airway is secured, provide 1 breath every 6 seconds (10 breaths/min) with continuous compressions 3, 2

Shockable Rhythms (VF/Pulseless VT) Management

For ventricular fibrillation and pulseless ventricular tachycardia, immediate defibrillation with minimal compression interruption is critical, followed by immediate resumption of CPR. 2

• Deliver biphasic shocks at 120-200 J (manufacturer-specified) or monophasic 360 J 2
• Resume CPR immediately after shock delivery for a full 2-minute cycle before the next rhythm check 2
• Establish IV/IO access and administer epinephrine 1 mg every 3-5 minutes 2
• For refractory VF/pVT after 2-3 shocks, either amiodarone or lidocaine may be used—the 2018 update clarified that both are considered equivalent, as neither has been shown to improve long-term survival or neurological outcomes 3
  • Amiodarone: 300 mg bolus, then 150 mg 3, 2
  • Lidocaine: 1-1.5 mg/kg, then 0.5-0.75 mg/kg 3, 2

Critical Caveat on Antiarrhythmics

The evidence shows that while amiodarone and lidocaine improve short-term outcomes like ROSC and hospital admission, no antiarrhythmic drug has demonstrated improved survival to discharge or favorable neurological outcomes. 3 Treatment recommendations are based primarily on potential benefits in witnessed arrests where time to drug administration is shorter. 3

Non-Shockable Rhythms (PEA/Asystole) Management

For pulseless electrical activity and asystole, immediate high-quality CPR without delay and early epinephrine administration are the priorities. 2

• Begin CPR immediately without waiting for rhythm analysis 2
• Administer epinephrine 1 mg IV/IO as soon as possible, then every 3-5 minutes 2
• Systematically search for and treat reversible causes (H's and T's) while CPR continues 2
  • H's: Hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia 2
  • T's: Tension pneumothorax, tamponade (cardiac), toxins, thrombosis (pulmonary), thrombosis (coronary) 2
• Perform rhythm checks every 2 minutes during CPR cycles 2
• If rhythm converts to VF/pVT, switch to the shockable-rhythm algorithm 2

Advanced Airway Management

The 2019 focused update addressed the ongoing debate about advanced airway strategies, emphasizing that airway placement must never cause prolonged interruptions in chest compressions. 3

• Begin with bag-mask ventilation using a 30:2 compression-ventilation ratio 2
• Consider advanced airway (endotracheal tube or supraglottic device) only when it can be placed without prolonged compression interruptions 3, 2
• Immediately confirm airway placement with waveform capnography—this is mandatory, not optional 3, 2
• After advanced airway placement, provide continuous compressions with 1 breath every 6 seconds 3, 2

Airway Choice Equipoise

The 2015 International Consensus noted equipoise between bag-mask ventilation, supraglottic airways, and endotracheal intubation as initial airway strategies. 3 The choice depends on provider skill, patient factors, and the ability to place the device without interrupting compressions. 3

CPR Quality Monitoring

Physiological monitoring during CPR helps guide the quality of resuscitation efforts and should be used when available. 3, 2

• Use quantitative waveform capnography with a target PETCO₂ > 10 mmHg (ideally 10-20 mmHg during CPR) 3, 2
• PETCO₂ < 10 mmHg signals inadequate CPR quality and should prompt immediate corrective actions 3, 2
• When available, monitor intra-arterial pressure targeting a diastolic (relaxation-phase) pressure > 20 mmHg 3, 2
• However, do not use ETCO₂ cutoff values alone as a mortality predictor or for decisions to terminate resuscitation 3

Recognition of ROSC

Return of spontaneous circulation is confirmed by multiple simultaneous indicators, not just pulse palpation. 3, 2

• Palpable pulse and measurable blood pressure 3, 2
• Abrupt sustained increase in PETCO₂ to ≥ 40 mmHg (typically > 40 mmHg) 3, 2
• Spontaneous arterial pressure waveforms on invasive monitoring 3, 2

Post-ROSC Care

The 2020 guidelines introduced a comprehensive post-cardiac arrest care algorithm emphasizing structured, multidisciplinary care as a critical component of the Chain of Survival. 3

Immediate Post-ROSC Priorities

• Avoid hypoxia while also avoiding hyperoxia 3
• Use 100% inspired oxygen until arterial oxygen saturation or PaO₂ can be measured reliably, then titrate to SpO₂ 92-98% 3, 2
• Maintain PaCO₂ within normal physiological range 3
• Target hemodynamic goals including mean arterial pressure ≥ 65 mmHg 3, 2

Targeted Temperature Management

• Select and maintain a constant target temperature between 32°C and 36°C for patients in whom temperature control is used 3
• TTM is recommended for adults with out-of-hospital cardiac arrest with initial shockable rhythm who remain unresponsive after ROSC 3
• TTM is suggested for other cardiac arrest scenarios 3

Antiarrhythmic Drugs Post-ROSC

There is insufficient evidence to recommend routine initiation or continuation of antiarrhythmic medications after ROSC. 3 The 2018 update specifically noted that no study has evaluated amiodarone for post-ROSC prophylaxis. 3 Prophylactic lidocaine may be considered only during EMS transport when recurrent VF/pVT would be difficult to manage. 2

Neuroprognostication

The 2020 guidelines emphasized that neuroprognostication must use a multimodal approach and should not be based on any single finding. 3

• Delay neuroprognostication until adequate time has passed to avoid confounding by medication effects or transiently poor examination 3
• Perform multimodal neuroprognostication at a minimum of 72 hours after return to normothermia, though individual tests may be obtained earlier 3
• Use clinical examination, serum biomarkers, electrophysiological tests, and neuroimaging in combination 3

Special Circumstances

Cardiac Arrest in Pregnancy

The best outcomes for both mother and fetus are achieved through successful maternal resuscitation. 3

• Provide high-quality CPR with relief of aortocaval compression through left lateral uterine displacement 3
• For pregnant women with fundus height at or above the umbilicus without ROSC despite usual measures plus manual left lateral uterine displacement, prepare to evacuate the uterus while resuscitation continues 3
• Immediately prepare for perimortem cesarean delivery (ideally within 5 minutes of arrest) while BLS and ACLS interventions continue 3

Opioid-Associated Cardiac Arrest

The 2020 guidelines introduced new algorithms for opioid-associated emergencies, emphasizing that standard resuscitative measures take priority over naloxone administration. 3

• Do not delay activating emergency response systems while awaiting response to naloxone 3
• For patients in cardiac arrest, focus on high-quality CPR (compressions plus ventilation) rather than naloxone administration 3
• Naloxone is recommended for respiratory arrest associated with opioid toxicity via IV, IM, subcutaneous, IO, or intranasal routes 3

Extracorporeal CPR (ECPR)

The 2019 focused update addressed ECPR as an emerging rescue therapy for select patients. 3

• ECPR is suggested as a reasonable rescue therapy for select patients with cardiac arrest when initial conventional CPR is failing in settings where this can be implemented 3
• The decision to use ECPR depends on available resources, personnel expertise, and patient selection criteria 3

Mechanical CPR Devices

Automated mechanical chest compression devices are not recommended for routine use but have specific applications. 3

• Suggest against routine use of automated mechanical chest compression devices 3
• They are reasonable alternatives in situations where sustained high-quality manual compressions are impractical or compromise provider safety 3

Common Pitfalls to Avoid

• Never interrupt compressions for prolonged advanced airway placement—only brief pauses are acceptable 2
• Avoid excessive ventilation, especially after airway placement, as it raises intrathoracic pressure and reduces venous return 2
• Do not use ETCO₂ cutoff values alone to decide when to terminate resuscitation 3
• Do not give routine prophylactic antiarrhythmic drugs after ROSC—no survival benefit has been demonstrated 3, 2
• Do not delay defibrillation while preparing medications for shockable rhythms 2

Recovery and Survivorship

The 2020 guidelines added recovery as an additional link in the Chain of Survival. 3

• Provide recovery expectations and survivorship plans addressing treatment, surveillance, and rehabilitation at hospital discharge 3
• Address the physical, social, emotional, and functional sequelae of cardiac arrest 3
• Optimize transitions of care to support independent function 3