Every five years, the American Heart Association (AHA) updates its Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) to reflect the latest science and best practices.
For EMS and nursing students, understanding these updates is critical, not just for certification exams but also for providing the most effective, evidence-based care in real-world emergencies.
This summary compares the 2025 updates with the 2020 guidelines, focusing on key changes across ACLS, BLS, PALS, and Neonatal Life Support.
View the 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or download the Guideline Update Highlights PDF.
It’s important to note that these are recommendations, not necessarily best practices for your local area. The NREMT is updating its exams throughout 2026; you can learn more about the updates here.
Section Links
Advanced Cardiovascular Life Support (ACLS)
Basic Life Support (BLS)
Pediatric Advanced Life Support (PALS)
Neonatal Life Support (NLS)
Advanced Cardiovascular Life Support (ACLS)
Defibrillation: Double Sequential and Vector Change Not Established
In 2025, the AHA confirmed that double sequential external defibrillation (DSED) and vector-change defibrillation remain “not established” for patients with refractory ventricular fibrillation or pulseless ventricular tachycardia after three failed shocks.
In 2020, these methods were mentioned but not yet evaluated; the evidence remains insufficient to recommend their routine use.
Vascular Access: IV First, IO if Necessary
Intravenous (IV) access is now the preferred route for medication delivery, as new studies show higher rates of sustained ROSC compared to intraosseous (IO) access. IO access remains appropriate when IV placement is not feasible.
In 2020, IV and IO were considered equally acceptable routes.
Epinephrine Timing: After Initial Shocks Fail
The 2025 AHA circular cardiac arrest algorithm emphasizes continuous CPR with minimal interruptions, followed by timed medication delivery. Initial epinephrine should be administered after the first failed defibrillation. Epinephrine should be given every 3–5 minutes, while amiodarone or lidocaine is used only after persistent VF/pVT. Continuous waveform capnography helps monitor CPR effectiveness; low EtCO₂ readings suggest poor compressions or prolonged arrest.
Waveform capnography now plays a central role in monitoring CPR effectiveness — a drop in EtCO₂ signals declining cardiac output and prompts immediate reassessment of CPR quality.
The 2020 guideline already recommended early epinephrine for nonshockable rhythms, but was less specific about timing for shockable cases.
The circular algorithm visually shows the flow of actions during cardiac arrest, including:
- Starting CPR and oxygenation,
- Early defibrillation sequence,
- Epinephrine every 3–5 minutes,
- Amiodarone/lidocaine for refractory VF/pVT,
- Advanced airway placement and EtCO₂ monitoring,
- Treating reversible causes (the H’s and T’s),
- Transition to post-cardiac arrest care once ROSC is achieved.
Head-Up CPR: Not Recommended Outside Research
The AHA now advises against performing head-up CPR except in a research setting, as there’s insufficient evidence of benefit.
In 2020, this concept was still experimental without formal endorsement.
Post-Arrest Care: MAP and Temperature Targets
Maintain a mean arterial pressure (MAP) ≥65 mmHg and temperature control between 32–37.5°C for at least 36 hours for comatose patients after ROSC. Multimodal neuroprognostication should guide care decisions, and emotional health screening for survivors and families is recommended before discharge.
In 2020, the emphasis was on targeted temperature management (TTM) and on avoiding hypotension, without specifying a duration for temperature control.
Basic Life Support (BLS)
Ventilation During Respiratory Arrest
During respiratory arrest with a pulse, rescuers should deliver one breath every six seconds (about 10 breaths per minute), ensuring visible chest rise.
The 2020 guideline also emphasized visible chest rise but allowed a slightly wider range for respiratory support timing.
Compression–Ventilation Ratio: 30:2 Until Advanced Airway
The 30:2 ratio remains the standard until an advanced airway is placed, reinforcing the importance of visible chest rise and avoiding hyperventilation.
This has not changed from the 2020 guideline, which first established the 30:2 ratio as standard practice.
Defibrillation Pad Placement in Women
When placing defibrillator pads, it is now considered reasonable to adjust a bra rather than remove it to expedite pad placement and preserve modesty.
The 2020 guideline noted that women in cardiac arrest experience significantly lower rates of public-access defibrillation compared with men. The need for a bare chest may be a contributing factor, so the AHA provides the option to adjust rather than remove the bra, which may decrease the rescuer’s hesitation to expose a woman’s chest.
Obesity: No Modifications to CPR
The 2025 AHA guidelines clarify that standard CPR techniques should be performed on obese patients; no evidence supports modifying compressions or ventilation.
In 2020, this topic was not explicitly addressed.
Mechanical CPR Devices
Routine use of mechanical compression devices is not recommended, but they may be considered when manual compressions are unsafe, impractical, or ineffective.
This aligns with 2020 guidance but now includes stronger language about minimizing pauses when using such devices.
Foreign Body Airway Obstruction
For adults with severe foreign body airway obstruction, rescuers should perform five back blows followed by five abdominal thrusts, repeating the sequence until the obstruction clears or the patient becomes unresponsive. For obese/pregnant adults, rescuers should perform the same, but substitute chest thrusts instead of abdominal thrusts.
The 2020 guideline recommended abdominal thrusts but did not include alternating back blows for adults.
Dispatcher and Community Response
Dispatchers should continue giving Hands-Only CPR instructions for adults and conventional CPR (compressions and breaths) for children, as they usually have a respiratory component to their cardiac arrest. The 2025 update also encourages public access to naloxone alongside AEDs and supports take-home naloxone programs with training. Narcan should be administered as long as it does not delay chest compressions.
The 2020 guideline emphasized telecommunicator-assisted CPR but did not integrate overdose response into the community chain of survival.
Pediatric Advanced Life Support (PALS)
High-Quality CPR: Minimize Pauses
Chest compression pauses should be less than 10 seconds to maintain perfusion.
The 2020 guideline emphasized minimizing interruptions but did not set a defined time limit.
Compression Technique: Updated for Infants
For infants, rescuers should use the heel of one hand or the two-thumb encircling technique. The two-finger method is no longer recommended.
In 2020, the two-finger method was still acceptable for single rescuers.
Foreign Body Airway Obstruction
For children with severe foreign body airway obstruction, alternate five back blows and five abdominal thrusts. For infants with severe foreign-body airway obstruction, perform 5 back blows and 5 chest thrusts.
The 2020 guideline allowed similar interventions but did not emphasize the specific alternation sequence.
Epinephrine for Nonshockable Rhythms
Administer epinephrine as early as possible for nonshockable cardiac arrest rhythms.
The 2020 guideline encouraged early administration but did not label timing as critical.
Monitoring During CPR
Use end-tidal CO₂ (EtCO₂) and arterial diastolic pressure to assess CPR quality. Do not rely on EtCO₂ alone to terminate resuscitation. Target diastolic pressures of ≥25 mmHg for infants and ≥30 mmHg for children.
In 2020, EtCO₂ was recommended for airway confirmation and monitoring, but not yet tied to resuscitation decision-making.
Post-Cardiac Arrest Care
Maintain systolic or mean arterial pressures above the 10th percentile for age, and use EEG within 72 hours for neuroprognostication. Evaluate survivors for physical, emotional, and cognitive needs throughout the first year.
In 2020, the focus was on avoiding hypotension and hypoxia, with less emphasis on long-term recovery.
Neonatal Life Support (NLS)
Umbilical Cord Management
Deferred cord clamping for at least 60 seconds is recommended for term and preterm infants not requiring immediate resuscitation. Intact-cord milking may be reasonable for nonvigorous infants ≥35 weeks.
The 2020 guideline supported delayed clamping but discouraged intact-cord milking due to limited data.
Airway and Ventilation
Begin with peak pressures of 20–30 cm H₂O at a rate of 30–60 breaths per minute. Video laryngoscopy can aid training and visualization, while laryngeal mask airways (LMAs) are now acceptable as a primary or backup airway for infants ≥34 weeks.
In 2020, LMAs were mainly considered backup devices, and video laryngoscopy was only briefly mentioned.
Oxygen and Monitoring
Apply pulse oximetry early when providing respiratory support or supplemental oxygen. For preterm infants under 32 weeks, start FiO₂ at 30–100%, adjusting to achieve oxygen saturation goals.
The 2020 guideline recommended starting with room air or low-concentration oxygen but did not include a range.
Chest Compressions
Perform compressions on the lower third of the sternum, switching rescuers every 2–5 minutes and reassessing heart rate during transitions.
In 2020, compression location and technique were similar, but the timing for switching rescuers was not specified.
Time to Apply These New Guidelines
The 2025 AHA CPR and ECC Guidelines build on a foundation of proven science, refining techniques to improve survival and neurological outcomes. For students, these updates are more than exam material; they shape how you’ll save lives in the field and clinical settings.
Staying current with the latest algorithms, compression techniques, and post-arrest care recommendations ensures your practice aligns with the best available evidence and gives every patient their best chance at recovery.
