Peer-reviewed by Dr. Abdolghader Pakniyat
Major Structural Changes
New Ethics Chapter
- First comprehensive ethics chapter in AHA guidelines
- Emphasizes healthcare professionals’ obligation to address health inequities and social determinants of health
- Provides frameworks for difficult decisions (shared decision-making, termination of resuscitation, organ donation)
Unified Chain of Survival
- Single chain now applies to both adult and pediatric, in-hospital and out-of-hospital cardiac arrest
- Emphasizes prevention and preparedness as first links
Adult Basic Life Support
Foreign Body Airway Obstruction (FBAO) – MAJOR CHANGE
- NEW approach: 5 back blows followed by 5 abdominal thrusts (repeated cycles)
- Previously started with abdominal thrusts only
- Aligns with pediatric recommendations for consistency
CPR Techniques
- Head tilt-chin lift now recommended for trauma patients if jaw thrust fails (airway takes priority)
- Bra adjustment may be reasonable instead of removal for defibrillator pad placement
- Obesity: Use same CPR techniques as for patients without obesity
- Mechanical CPR devices: NOT routinely recommended (may consider only in specific challenging situations)
Ventilation Updates
- Emphasizes visible chest rise
- Avoid both hypoventilation AND hyperventilation
- 30:2 compression-ventilation ratio reaffirmed (allows monitoring of ventilation adequacy)
Pediatric Basic Life Support
Infant Chest Compressions – MAJOR CHANGE
- Recommended: 2-thumb encircling hands OR heel of 1 hand
- NO LONGER RECOMMENDED: 2-finger technique
- Based on superior depth achievement
Pediatric FBAO – MAJOR CHANGE
- Children: 5 back blows followed by 5 abdominal thrusts (cycles)
- Infants: 5 back blows followed by 5 chest thrusts (cycles)
- Previously started with abdominal thrusts for children
CPR Quality
- NEW: Minimize interruptions; pauses should be <10 seconds
- Based on evidence linking longer pauses to worse outcomes
Neonatal Life Support
Umbilical Cord Management
- Term infants: Defer cord clamping ≥60 seconds (updated from previous guidance)
- Preterm <37 weeks: Defer cord clamping ≥60 seconds (recommended based on mortality reduction)
- Nonvigorous term/late preterm: Intact cord milking may be reasonable vs immediate clamping
Airway Management – NEW
- Video laryngoscopy can be useful for intubation (increased success rates)
- Laryngeal mask reasonable as alternative to intubation for ≥34 weeks when face mask fails
- Laryngeal mask may be reasonable as PRIMARY device instead of face mask for ≥34 weeks
Ventilation & Oxygen
- Initial peak pressures: 20-30 cm H₂O (clarified range)
- Ventilation rate: 30-60/min
- Pulse oximeter: Place as soon as possible when giving respiratory support
- Preterm <32 weeks: “may be reasonable to start 30%–100% for <32 wk on support, then titrate.
Chest Compressions
- Position: Lower third of sternum (above xiphoid) – clarified location
- Change compressors: Every 2-5 minutes reasonable
Adult Advanced Life Support
Defibrillation
- Vector change defibrillation: Benefit uncertain (downgraded from previous consideration)
- Double sequential defibrillation: Benefit uncertain (downgraded)
- ≥200 J is reasonable (AF); 200 J may be reasonable (AFL
Vascular Access
- IV access first – reaffirmed as preferred
- IO access: Reasonable if IV unsuccessful, but associated with lower ROSC rates vs IV
Medications
- Epinephrine timing (shockable rhythm): Give AFTER initial defibrillation attempts fail (clarified timing)
- Vasopressin: No advantage over epinephrine alone (reaffirmed)
- Other antiarrhythmics (β-blockers, bretylium, procainamide, sotalol): Uncertain benefit
Adjuncts
- Head-up CPR: NOT recommended except in clinical trials (new restriction based on weak evidence)
Wide-Complex Tachycardia
- Synchronized cardioversion recommended for unstable patients (reaffirmed)
- Also for stable patients when vagal/pharmacologic therapy fails
Bradycardia – NEW
- Temporary transvenous pacing reasonable for refractory unstable bradycardia
Pediatric Advanced Life Support
Medications
- Epinephrine (non-shockable): Give as early as possible (ideally <3 minutes)
Monitoring During CPR
- ETCO₂: May monitor CPR quality if advanced airway present
- ETCO₂ ≥20 mmHg: Associated with better outcomes
- IMPORTANT: Don’t use ETCO₂ cutoff alone to terminate resuscitation
- Arterial blood pressure targets during CPR:
- Infants: Diastolic ≥25 mmHg
- Children ≥1 year: Diastolic ≥30 mmHg
Post-Arrest Management
- Blood pressure: Maintain systolic and MAP >10th percentile for age (updated target)
Supraventricular Tachycardia – NEW
- May consider IV procainamide, amiodarone, OR sotalol if refractory to adenosine/cardioversion
Neuroprognostication – NEW
- Use MULTIPLE modalities (no single test sufficient)
- EEG: Reasonable to use within 72 hours (along with other tests)
- Cough/gag reflexes: NOT well established for prognosis
Post-Cardiac Arrest Care (Adult)
Hemodynamics
- MAP target: ≥65 mmHg minimum (reaffirmed)
- Higher MAP targets show no benefit
Temperature Management
- Duration: ≥36 hours for unresponsive patients (updated minimum duration)
- Temperature range: 32-37.5°C
Diagnostics – NEW
- CT head-to-pelvis: May be reasonable to investigate arrest cause/complications
- Echocardiography/POCUS: May be reasonable for identifying diagnoses requiring intervention
Coronary Intervention
- Angiography recommended before discharge for suspected cardiac etiology, especially with:
- Shockable rhythm
- LV dysfunction
- Severe ischemia evidence
Mechanical Support – NEW
- Temporary mechanical circulatory support may be considered for refractory cardiogenic shock
Myoclonus – NEW
- Do NOT treat myoclonus without EEG evaluation(no benefit, potential harm)
Neuroprognostication – NEW
- Continuous EEG background without discharges within 72 hours may support favorable prognosis
Recovery/Survivorship
- Structured assessment for emotional distress recommended before hospital discharge (for patients AND caregivers)
Special Circumstances
Asthma – NEW
- ECLS may be reasonable for life-threatening asthma
- Volatile anesthetics may be considered
Hyperkalemia
- IV calcium effectiveness uncertain in cardiac arrest (downgraded from previous guidance)
Hypothermia – NEW
- ECLS: Reasonable using prognostication scores (HOPE, ICE)
- May use ECLS for severe hypothermia (<28°C) NOT in arrest
Hyperthermia – NEW
- Ice water immersion (1-5°C) recommended over other cooling methods
- Target cooling rate: ≥0.15°C/min
Left Ventricular Assist Devices (LVAD) – NEW
- Perform chest compressions for unresponsive patients with impaired perfusion
- Start compressions immediately while assessing device function
Pregnancy
- Resuscitative delivery (replacing “perimortem cesarean”): Complete by 5 minutes
- ECPR: Reasonable for pregnant/peripartum patients
- Amniotic fluid embolism: Use massive transfusion protocol
Opioid Overdose
- Naloxone in cardiac arrest: May be reasonable if doesn’t interfere with CPR
- Discharge naloxone: Provide to patients treated for overdose
Systems of Care
Community Initiatives
- Bundle approach reasonable to improve lay rescuer response
- Instructor-led training: Effective
- Mass media campaigns: May be considered
- CPR certification requirements: May be reasonable
Naloxone Access – NEW
- Public policies should allow possession and use with immunity
- Distribution programs can reduce opioid mortality
Prevention – NEW
- Safety huddles effective for reducing IHCA in high-risk patients
Debriefing – NEW
- Incorporate both immediate (hot) AND delayed (cold) debriefing
Team Composition – NEW
- OHCA: ALS clinician presence beneficial; adequate team size for defined roles
- IHCA: ALS-trained teams with clearly defined roles and simulation training
Transport Decisions
- On-scene resuscitation: Prioritize achieving ROSC before transport (most cases)
- EMS: Should be prepared for on-scene termination with death notification training
ECPR Centers – NEW
- Develop patient selection criteria for equity and limiting futility
- Regionalization reasonable
- Rapid transport for ECPR may be considered for highly selected OHCA patients
Organ Donation – NEW
- Institutions should develop systems for facilitating organ donation after cardiac arrest
Recovery – NEW
- Integrated systems needed: assess before discharge, reassess after discharge, ongoing support
Education Science
Feedback Devices
- Recommended for both healthcare professionals AND lay rescuers during training (stronger evidence)
Technology
- Virtual Reality: May be reasonable for KNOWLEDGE acquisition; should NOT be used for SKILLS training
- Augmented Reality: May be considered for real-time CPR feedback
- Gamified learning: May be reasonable (weak evidence)
Training Methods – NEW
- Rapid-cycle deliberate practice: May be reasonable for BLS/ALS training
- Teamwork training: Recommended (specific emphasis)
Opioid Overdose Training
- Recommended for lay rescuers
- Increases knowledge, willingness, naloxone use
Disparities – MAJOR EMPHASIS
- Focus training on:
- Specific racial/ethnic populations
- Low socioeconomic status areas
- Linguistically isolated communities
- Address barriers to performing CPR on women
- Provide cost-effective methods and materials in diverse languages
School Training – NEW
- Start CPR training before age 12 to increase willingness/confidence later
Alternative Training Objects – NEW
- Usefulness of household objects (pillows, etc.) for compression practice: NOT well established
Debriefing & Cognitive Aids – NEW
- Scripted debriefing: May be reasonable for instructors
- Cognitive aids for healthcare professionals: May be reasonable during resuscitation
- Cognitive aids for lay rescuers: NOT recommended (causes delays)
Key Statistical Notes
- 760 total recommendations
- Only 1.4% (11 recommendations) based on Level A evidence (high-quality RCTs)
- 233 Class 1 (strong) recommendations
- 451 Class 2 (moderate/weak) recommendations
- 76 Class 3 (no benefit or harm) recommendations
The guidelines emphasize the urgent need for more high-quality resuscitation research funding and support.
