Peer-reviewed by Dr. Abdolghader Pakniyat
The useful question for a resuscitation team is what to change in practice, what to keep doing, and where the evidence remains uncertain. This selected review of the 2025 AHA CPR guidelines separates adult, pediatric and newborn care. It is not a complete resuscitation algorithm.
Major Structural Changes
The 2025 AHA guidelines combine the adult and pediatric in-hospital and out-of-hospital chains of survival. Newborn care has a separate chain. A common diagram does not mean identical ventilation, drug or delivery-room algorithms.
This is a selected implementation review, not a list of entirely new treatments. Some recommendations are revised; others are reaffirmed. The ethics chapter expands discussion of equity and difficult decisions, but ethics was also addressed in earlier AHA guidelines. Executive summary.
Adult Basic Life Support
Change the choking drill. For a responsive adult with severe obstruction, activate emergency help and alternate 5 back blows with 5 abdominal thrusts. Use chest thrusts instead when the abdomen cannot be encircled or in late pregnancy. If the patient becomes unresponsive, start CPR with compressions; remove only a visible object when opening the airway. Never perform a blind finger sweep.
Keep ventilation effective, not excessive. Visible chest rise is a practical check that air is entering the lungs. Excessive ventilation raises intrathoracic pressure and can impair venous return. The familiar 30:2 sequence before an advanced airway remains appropriate for conventional adult CPR; this is not a new compression ratio. Mechanical compression devices are still not recommended routinely. Adult BLS.
Pediatric Basic Life Support
Retire two-finger infant CPR. Use two thumbs with encircling hands or the heel of one hand; use the one-hand technique if the chest cannot be encircled. The change addresses inadequate compression depth.
For responsive children with severe choking, alternate 5 back blows with 5 abdominal thrusts. For infants, alternate 5 back blows with 5 heel-of-one-hand chest thrusts, never abdominal thrusts. Activate emergency help. If unresponsive, begin CPR with compressions without a pulse check; remove only visible objects and avoid blind finger sweeps.
Breaths remain important because pediatric arrest frequently follows respiratory failure. Minimize interruptions and keep compression pauses under 10 seconds; protecting blood flow is an established principle, not a newly discovered intervention. These infant/child recommendations are distinct from resuscitation at birth. Pediatric BLS.
Neonatal Life Support
At birth, a rising heart rate is the main sign that ventilation is working. Provide ventilation within 60 seconds for apnea, gasping or persistent heart rate below 100/min despite initial steps. The updated range is 30–60 inflations/min. Initial peak pressure of 20–30 cm H₂O is reasonable, then titrate to effective ventilation rather than treating pressure as a fixed prescription.
For newborns not needing immediate resuscitation, defer cord clamping for at least 60 seconds. Do not delay needed ventilation. Intact cord milking may be reasonable in nonvigorous infants at ≥35 weeks; it should not be performed below 28 weeks.
For newborns receiving respiratory support at birth, initial oxygen options that may be reasonable depend on gestation: 21% at ≥35 weeks; 21%–30% at 32–34+6 weeks; 30%–100% below 32 weeks. Titrate with preductal oximetry to age-specific targets; the wide range reflects uncertainty, not permission to leave oxygen unchanged. Neonatal guidance.
Adult Advanced Life Support
Update cardioversion settings. For synchronized cardioversion with currently US-approved biphasic devices, an initial ≥200 J is reasonable for atrial fibrillation; 200 J may be reasonable for atrial flutter. Escalate after failure according to the device. Confirm synchronization and provide appropriate sedation when feasible. Sustained polymorphic VT instead requires an immediate high-energy unsynchronized shock; pulseless VT follows the arrest algorithm.
IV remains the first access attempt in adult arrest; use IO when IV fails or is not feasible. Access must not displace compressions or prompt defibrillation.
AHA considers benefit from vector change or double sequential defibrillation unestablished for VF/pVT persisting after ≥3 consecutive shocks. Do not present either as mandatory rescue therapy. Head-up CPR is restricted to clinical trials. These are AHA recommendations; ERC and ILCOR wording should not be silently substituted. Adult ALS.
Pediatric Advanced Life Support
For an initial nonshockable rhythm, give epinephrine as early as possible. A proposed three-minute target should not become permission to wait. Unlike the adult IV-first recommendation, initial pediatric IV or IO access depends on availability, expertise and speed.
When an arterial line is already present during CPR, it may be reasonable to target diastolic pressure ≥25 mmHg in infants and ≥30 mmHg in children aged at least one year. These goals connect compression performance to perfusion; they do not justify interrupting CPR to insert a line.
After arrest, maintain systolic and mean arterial pressure above the 10th percentile for age, using appropriate pediatric reference charts. Use several modalities and timepoints for neurological prognosis. Neither an isolated ETCO₂ value nor a single neurological test should decide when treatment stops. Pediatric ALS.
Post-Cardiac Arrest Care (Adult)
For adults not following verbal commands after ROSC, use protocolized temperature control within 32–37.5°C; continuing for at least 36 hours is reasonable. This is not a requirement to cool every patient to 33°C. Avoid hypotension, with MAP ≥65 mmHg as a minimum rather than a ceiling.
New diagnostic recommendations support selected CT or echocardiography/POCUS to identify the cause and complications. Imaging must answer a clinical question, not delay an urgent intervention. Persistent ST elevation with suspected cardiac cause warrants emergency angiography; without ST elevation and with suspected cardiac cause, consider emergency angiography in cardiogenic shock, recurrent ventricular arrhythmias or significant ongoing ischemia.
Obtain EEG promptly for post-arrest myoclonus. Do not give treatment just to suppress myoclonus that lacks an EEG correlate; absence of an EEG recording is not proof of no correlate. Treat clinically apparent seizures. Prognosis requires multimodal assessment after confounders are addressed. Adult post-arrest guidance.
Special Circumstances
In pregnancy, aortocaval compression can impair venous return. With fundal height at or above the umbilicus, provide manual left uterine displacement during compressions. Prepare for resuscitative delivery immediately; if standard resuscitation has not achieved ROSC, aim to complete delivery by 5 minutes. For in-hospital arrest, perform it at the arrest location rather than losing time in transfer.
For suspected opioid-associated respiratory arrest with a pulse, ventilation and naloxone are complementary. In cardiac arrest, naloxone must not delay CPR or defibrillation.
The uncertain benefit of calcium in suspected hyperkalemic cardiac arrest is not a recommendation to withhold calcium from a patient with a pulse and dangerous hyperkalemic ECG changes. Hypothermia, heatstroke, asthma and LVAD emergencies each need their own pathway; an abbreviated list cannot safely replace those indications and safeguards. Special-circumstances chapter.
Systems of Care
For most out-of-hospital arrests, prioritize effective resuscitation on scene over moving a patient during ongoing CPR. Transport for ECPR may be considered for highly selected adult OHCA patients within an established pathway. Transport is a treatment decision with a destination and purpose, not a substitute for resuscitation.
At implementation, assign roles, check staffing and equipment, and rehearse the escalation route. Add safety huddles for high-risk inpatients and combine immediate with later debriefing. Review actual delays and interruptions rather than simply recording course attendance.
Termination decisions require the applicable validated rule, clinical context and local policy; this summary supplies no universal stop time. Survivors and caregivers also need assessment, discharge planning and continuing support. Systems guidance.
Education Science
Practice the changes that alter hand movements and decisions: choking sequences, infant compressions and cardioversion settings. Use compression-feedback devices in training, then repeat the skill under realistic team conditions.
Virtual reality may help knowledge acquisition, but AHA does not recommend it for acquiring CPR skills. A screen cannot establish that a learner produces adequate compression depth. Rapid-cycle deliberate practice and structured debriefing may help; neither should be sold as a guaranteed survival intervention.
Healthcare-professional cognitive aids may be reasonable during resuscitation. Lay-rescuer cognitive aids are not recommended during resuscitation because delays can outweigh benefits. Match teaching language and access to the community, and evaluate demonstrated performance. Education guidance.
Key Statistical Notes
The 2025 document contains 760 recommendations. Their strength and evidence quality are different questions: a strong recommendation does not necessarily mean randomized-trial certainty. Read “reasonable,” “may be considered” and “not recommended” as distinct judgments, not interchangeable wording.
Evidence since publication: the 2026 ICECAP trial found no improvement in neurological recovery with longer durations of 33°C cooling among 1,158 selected adult out-of-hospital arrest survivors cooled rapidly. It tested cooling duration, not whether temperature control can be abandoned. This result does not directly replace AHA’s total temperature-control recommendation.
Official sources and related learning
The linked chapters above are the primary recommendations. The AHA 2025 Highlights PDF is a selective publication, not a complete bedside algorithm. Check the chapter, patient population and local protocol before adopting an isolated bullet.
Related EMMA reading: adult defibrillator pad placement; oxygen during defibrillation; when to stop adult CPR.
