2025 AHA Guidelines Update: Key Changes in CPR and ECC

Neonatal Life Support

Umbilical Cord Management

• For term and preterm neonates in stable condition, defer cord clamping ≥ 60 s.

• For non-vigorous neonates 35–42 weeks, intact-cord milking may be considered as an adjunct.

Ventilation and Airway

• Initiate PPV with peak pressures around 20–30 cm H₂O, titrating to adequate chest rise (standard NRP range; not a new AHA change).

• Ventilation rate 30–60 breaths per minute (remains NRP practice).

• Video laryngoscopy recognized as a useful tool for intubation.

• Laryngeal mask airway is appropriate when face-mask ventilation fails and may be used first-line in some settings (the ≥ 34-week threshold comes from NRP device sizing, not the AHA text).

Oxygen Therapy

• Apply pulse oximetry early and titrate FiO₂ to time-based SpO₂ targets rather than a fixed 30–100 % range.

Chest Compressions

• Compress over the lower third of the sternum, avoiding the xiphoid process.

Pediatric Basic Life Support

CPR Technique

• Limit interruptions to < 10 s.

• Use the two-thumb encircling method (or heel of one hand). The two-finger technique is no longer recommended.

Foreign Body Airway Obstruction (FBAO)

• Children: alternate 5 back blows and 5 abdominal thrusts.

• Infants: alternate 5 back blows and 5 chest thrusts (abdominal thrusts not recommended).

Adult Basic Life Support

Airway Management

• If jaw-thrust fails in trauma, head-tilt–chin-lift is acceptable despite cervical-spine concerns.

Ventilation

• Deliver enough tidal volume for visible chest rise while prioritizing high-quality compressions.

Compression-Ventilation Ratio

• Continue standard 30:2 compressions-to-breaths; asynchronous ventilations only after advanced airway placement.

Mechanical CPR

• Routine use is discouraged; may be considered when manual CPR is unsafe or impractical.

FBAO

• Repeat 5 back blows followed by 5 abdominal thrusts until cleared or unresponsive.

Pediatric Advanced Life Support (PALS)

Drug Administration

• In cardiac arrest with non-shockable rhythms, give epinephrine as early as possible, then every 3–5 min.

Monitoring During CPR

• EtCO₂ and arterial diastolic pressure help assess quality and detect ROSC.

  • Targets: ≥ 25 mm Hg (infants) and ≥ 30 mm Hg (children > 1 year).

  • No single parameter should guide termination of resuscitation.

SVT Management

• If vagal maneuvers, adenosine, and cardioversion fail, consider IV procainamide or amiodarone.

Post-Arrest Care

• Maintain systolic and mean arterial pressures above the 10th percentile for age.

Adult Advanced Life Support (ALS)

Defibrillation

• Vector change and dual sequential defibrillation are not recommended for routine use in refractory VF/pulseless VT (utility uncertain).

  See more here. 

Vascular Access

• IV preferred; IO if IV access fails or is delayed.

Vasopressors

• In shockable rhythms, delay epinephrine until after initial defibrillation.

• Epinephrine alone is preferred over combinations with vasopressin.

CPR Positioning

• Head-up CPR not recommended outside clinical trials.

• Perform compressions on a firm surface at rescuer knee height when possible.

Termination of Resuscitation

• The Universal TOR Rule applies (arrest not witnessed by EMS, no ROSC, no shocks).

Arrhythmia Management

• Wide-complex tachycardia with instability: synchronized cardioversion.

• Stable wide-complex: attempt vagal maneuvers and pharmacologic therapy.

AF / Flutter with RVR

• Use 200 J for synchronized cardioversion; avoid low-energy shocks and double cardioversion.

Bradycardia

• Atropine first; if ineffective, initiate transcutaneous pacing.

• Transvenous pacing is reasonable when bradycardia persists despite TCP and medical therapy (with expert consultation).

Post-Cardiac Arrest Care

Hemodynamics

• Maintain MAP ≥ 65 mm Hg; avoid hypotension.

Diagnostics

• Whole-body CT (from head to pelvis) may be considered after stabilization to identify arrest etiology or resuscitation-related injury.

Temperature Control

• Maintain core temperature 32–37.5 °C for ≥ 36 h in patients not following commands.

Myoclonus and Seizure Management

• Obtain EEG to evaluate for seizures.

• Treat confirmed seizures; avoid prognosticating based on myoclonus alone.

Cardiac Arrest in Special Circumstances

Asthma

• Consider ECLS or inhaled volatile anesthetics if standard therapy fails.

Hyperkalemia

• Continue standard ACLS management (IV calcium for ECG changes, insulin/glucose, β-agonists, bicarbonate as indicated). The AHA did not de-prioritize calcium.

Hypothermia

• Consider ECLS for profound hypothermia (core < 28 °C) when resources allow; HOPE and ICE scores are external decision aids, not formal AHA recommendations.

Hyperthermia

• Rapid cold-water immersion (1–5 °C) is recommended for exertional heat stroke; cool as rapidly as possible (no specific rate given by AHA).

LVAD Patients

• If unresponsive with impaired perfusion, begin CPR while troubleshooting the device. Read more on LVADs here. 

   

Pregnancy

• Initiate resuscitative hysterotomy immediately upon recognition of cardiac arrest with the goal of delivery ≤ 5 min.

• Consider ECPR if standard resuscitation fails.

• Use a balanced massive transfusion for suspected amniotic fluid embolism.

Opioid Overdose

• Naloxone may be given for suspected opioid-related cardiac arrest, but must not delay standard CPR and epinephrine administration.

References

• American Heart Association. 2025 Highlights of the Guidelines for CPR and ECC.

• AHA Algorithms: Adult BLS, Adult ALS, PALS, Post-Cardiac Arrest Care (2025 update).

• EMOttawa Blog: Braving the Electrical Storm in the ED (2020).