Cardiac arrest guidelines are often read as checklists: compression depth, shock timing, drug doses, airway decisions, post-ROSC targets. But the most important message from the 2025 Korean Guidelines for Cardiopulmonary Resuscitation and the 2025 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care is broader than any single intervention.
The field is moving from “what should the clinician do during the code?” toward “how should the entire system be built so that survival is more likely before, during, and after the code?”
That shift matters. In Korea, out-of-hospital cardiac arrest survival improved from 4.8% in 2013 to 9.2% in 2024, with favorable neurologic outcome rising from 2.3% to 6.3%. The Korean authors still describe outcomes as suboptimal, emphasizing the need for better bystander response, EMS performance, AED use, and post-arrest care. The AHA makes a similar point for the United States: despite advances, cardiac arrest survival remains low, with major variability by geography, race, ethnicity, rurality, and access to CPR/AED training.
The important question, then, is not simply “which guideline is better?” The better question is: what can emergency clinicians and EMS systems learn from the differences?
The shared foundation: ILCOR science, local implementation
Both documents draw from the same global evidence ecosystem. The Korean guideline explicitly states that ILCOR evidence summaries serve as the scientific foundation for national and regional guidelines, but that each council must adapt recommendations to local epidemiology, EMS structure, law, culture, and feasibility. The Korean update used task forces, PICO questions, GRADE methodology, ILCOR evidence, and review of AHA/ERC guidance.
The AHA likewise states that the 2025 CPR/ECC guidelines are closely aligned with 2025 ILCOR evidence evaluation and include a large body of recommendations across systems of care, neonatal resuscitation, pediatric and adult life support, special circumstances, post-arrest care, ethics, and education.
That shared foundation explains why the two guidelines are more similar than different. The differences are mostly about emphasis, implementation, and threshold for adopting newer interventions.
1. The Chain of Survival now extends beyond ROSC
The Korean update integrates adult, pediatric, OHCA, and IHCA chains into one simplified chain and explicitly adds rehabilitation and recovery as the final link. The AHA also consolidated its prior chains into a single six-link chain and emphasizes survivorship, rehabilitation systems, and inpatient-to-outpatient recovery support.
This is more than symbolic. It reflects a major philosophical shift. ROSC is not the endpoint. Survival with meaningful neurologic and functional recovery is the endpoint.
For EDs and EMS systems, this means post-arrest care should not stop at airway, pressors, temperature, and cath lab decisions. Survivorship pathways should include neuroprognostication discipline, rehabilitation referral, cognitive and emotional screening, family support, and follow-up. The AHA explicitly recommends systems that span inpatient and outpatient domains to evaluate cardiac arrest survivors for disabilities and provide ongoing recovery support.
2. AED access is still an implementation failure
The Korean guideline adds a recommendation that dispatchers guide callers not only through CPR, but also through locating and applying an AED. The rationale is straightforward: prehospital AED use remains low in Korea. The guideline also addresses a practical barrier: AED pads should be applied to the bare chest, with adjustment of underwear rather than removing the bra, given lower AED application rates in female patients.
The AHA similarly emphasizes public-access defibrillation, telecommunicator recognition, community education, mobile technologies, and bundled approaches to improve lay rescuer CPR and AED use.
This is one of the highest-yield areas for public health intervention. We do not need a new drug to improve many cardiac arrest outcomes. We need faster recognition, faster compressions, faster AED application, and fewer social or practical barriers to defibrillation.
3. Drowning is different: ventilation matters
A key Korean update is that trained first responders and healthcare providers should initiate resuscitation with rescue breathing in drowning-related arrest, where respiratory arrest is likely.
The AHA’s drowning section makes the same physiologic point: drowning typically progresses from hypoxic respiratory arrest to cardiac arrest, so resuscitation must focus on restoring breathing as well as circulation. It also states that appropriately trained rescuers may provide in-water breaths if doing so does not compromise rescuer safety.
This is an important corrective to overly simplistic “compression-only CPR” messaging. Compression-only CPR is useful for many adult sudden cardiac arrests, especially when a lay rescuer is unwilling or unable to provide breaths. But drowning is a hypoxic event. For trained rescuers, ventilation is not optional detail; it is central physiology.
4. Refractory VF is where the guidelines diverge most visibly
The Korean guideline states that for adult cardiac arrest with refractory shockable rhythms, trained healthcare providers may consider double sequential defibrillation or vector-change defibrillation when additional pads or defibrillators are immediately available.
The AHA is more cautious. It recognizes double sequential defibrillation as a potential treatment for shock-refractory VF, but states that reliable identification of shock-refractory VF and optimal delivery timing require further investigation before routine use is recommended.
This is the most headline-grabbing difference, but it should not distract from the basics. Before reaching for DSD, teams must verify pad position, pad contact, compression quality, peri-shock pause time, energy escalation, antiarrhythmic use, and reversible causes. DSD should not become a chaotic “last-ditch” maneuver that delays high-quality CPR or shocks.
A reasonable ED protocol would be conservative: after persistent VF/pVT despite standard defibrillation, confirm pads and contact, minimize pauses, use maximum appropriate energy, consider an alternate vector if feasible, and reserve DSD for trained teams under explicit local protocol.
5. Post-arrest temperature: broader targets, same central message
The Korean guideline revises post-resuscitation temperature management from 32–36 °C to 33–37.5 °C for at least 24 hours in comatose adults after ROSC. It also recommends post-ROSC targets including MAP at least 60–65 mmHg, SpO₂ 94–98%, PaCO₂ 35–45 mmHg, and glucose 144–180 mg/dL.
The AHA similarly emphasizes post-arrest care, targeted temperature management, hemodynamic stabilization, and fever avoidance. In pediatrics, for example, AHA recommends avoiding central temperatures above 37.5 °C and allows either hypothermic TTM followed by normothermic TTM or normothermic TTM alone in appropriate patients.
The practical message is no longer “cool everyone aggressively.” It is: control temperature, avoid fever, standardize care, and prevent secondary brain injury.
6. Routine cath lab activation after ROSC is narrowing
The Korean guideline recommends emergency coronary angiography only for patients with ST-segment elevation or evidence of cardiogenic shock.
This aligns with the broader direction of AHA and contemporary post-arrest evidence. The older reflex—“ROSC equals cath lab”—has become more selective. Persistent ST elevation, cardiogenic shock, recurrent ventricular arrhythmias, or strong evidence of ongoing ischemia still matter. But stable comatose patients without ST elevation should not automatically be rushed to the cath lab at the expense of diagnosis, stabilization, and neurologic care.
For emergency clinicians, this means the post-ROSC ECG is essential, but it is not the only decision point. Hemodynamics, electrical instability, arrest context, bedside echo, and alternative diagnoses remain critical.
7. Pediatric and neonatal updates emphasize technique and access
The Korean guideline now recommends public-access defibrillation for children aged at least 1 year and recommends the two-thumb encircling technique for infant compressions, rather than the two-finger technique. It also supports supraglottic airway devices and video laryngoscopy in neonatal resuscitation when resources and training permit.
The AHA similarly emphasizes pediatric conventional CPR with breaths, elimination of the two-finger infant compression technique, and neonatal use of video laryngoscopy and supraglottic airway devices in appropriate settings.
The theme is familiar: technique matters, but training and implementation determine whether technique reaches the patient.
8. Education is not a side issue
The Korean guideline recommends simulation-based training, hot or delayed debriefing, and feedback devices for CPR training. It also cautions against treating self-directed asynchronous online learning or blended learning as a standard substitute for traditional training.
The AHA also emphasizes debriefing, feedback, resuscitation team structure, defined roles, and quality improvement.
This is a critical point for hospital leaders. A resuscitation program is not created by buying defibrillators and uploading ACLS cards. It requires deliberate practice, role clarity, performance measurement, and post-event learning.
The practical take-home
The 2025 Korean and AHA CPR guidelines are not competing documents. They are two applications of the same evolving science to different systems.
The Korean update is especially useful because it highlights implementation barriers: low AED use, dispatcher action, sex-based AED application gaps, drowning physiology, and pragmatic post-arrest targets. The AHA update is useful because it provides a broad, modular, rigorously classified framework across systems of care, ethics, education, neonatal care, pediatric care, adult BLS/ALS, special circumstances, and post-arrest management.
For emergency departments and EMS systems, the most important changes are not exotic. They are operational:
Improve dispatcher-assisted AED use. Train for ventilation in hypoxic arrests such as drowning. Standardize refractory VF workflows before considering DSD. Prevent fever after ROSC. Avoid routine post-arrest cath lab activation without STEMI, shock, or ongoing ischemia. Build survivorship and rehabilitation into the chain of care. Use feedback and debriefing as quality tools, not educational afterthoughts.
The future of resuscitation is not only better algorithms. It is better systems.
