As expected, the 2025 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) was recently released and it contains a wealth of information about caring for cardiac emergencies.
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Many providers from all levels of healthcare skimmed the Highlights document to find the big changes that would need to be implemented in the coming months to better care for victims of cardiac arrest, non-arrest arrhythmias, airway obstructions and respiratory failure due to opioid overdose.
I did the same, but I also took the time to review the full Guidelines to learn more details about changes related to out-of-hospital care. Following is a quick overview of some of the changes that caught my attention as well as a few recommendations that I was surprised to see stayed the same.
Basic life support
Mechanical CPR
There is no doubt that the biggest news from the BLS section is the lack of a recommendation for mechanical CPR.
The guidelines actually note that “routine” use of mechanical CPR devices provides no documented benefit to patients and is not recommended. This is not a change from the 2020 Guidelines, but still a topic of great debate among EMS providers.
Both the 2020 and 2025 Guidelines do highlight that “use of mechanical CPR devices may be considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous for the health care professional, as long as rescuers strictly limit interruptions in CPR during deployment and removal of the device.” This is in line with the over-arching concept that high-quality CPR with minimized interruptions is the key to successful resuscitation.
Choking guidance
Another highlight in the BLS section includes switching to administering back blows first for foreign body airway obstruction in both adults and pediatric victims. Back blows are thought to be slightly more effective, so why not try them first? For infants, chest compressions are substituted for abdominal thrusts, but the back blows are still first in the sequence as they are in adults and children.
The two-finger technique for infant chest compressions has been eliminated as it was found to be ineffective. Rescuers may use either the heel of one hand or the 2-thumb encircling hands technique.
Bariatric CPR
Recognizing that 40% of adults in the United States are considered obese, the AHA included a new recommendation that CPR for these individuals be provided with the same techniques as “average” weight adults, as there is no evidence that standard techniques are ineffective in larger adults.
Ethics
Appropriately so, the topic of ethics has been moved into its own section of the AHA Guidelines and includes a related list of recommendations. Previous versions had ethical considerations woven throughout the full document.
The topic of ethics includes more than just determining brain death in hospitalized patients. EMS providers must incorporate ethics into protocols related to:
- Portable orders for life-sustaining treatment (POLST)
- Withholding and termination of resuscitation
- Family presence during resuscitation
- Initiatives to address inequities and minimize disparities in care
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Systems of care
The Guidelines include a broad section on systems of care. AHA highlights the need for organized systems of care to provide quality treatment across the entire continuum of care for a cardiac arrest patient. Agencies including EMS, fire, law enforcement, dispatch and hospitals must work together and be on the same page.
Community CPR training
Additionally, the Guidelines note efforts must be continued to improve lay rescuer response in our communities. AHA notes that only 41.7% of adult out-of-hospital cardiac arrest (OHCA) patients received bystander CPR. Only 12.6% of patients who suffered their OHCA in a public place had an AED applied. Certainly there is work to be done to train lay rescuers on CPR but to also place and encourage the use of public access AEDs.
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Stay and play vs. load and go
The Systems of Care section also reinforces a previous recommendation that cardiac arrest be treated where the patient is found unless extenuating circumstances dictate moving them. This means transport with ongoing CPR should be a rare exception. It is well documented that CPR and other care during transport are less effective and the practice generally involves more risk than benefit. ALS and BLS providers should follow termination of resuscitation guidelines and be trained in death notification.
ECMO
The use of extracorporeal CPR (ECMO or ECPR) has continued to grow in larger population centers and studies have shown encouraging results. The AHA gives the practice of on-scene ECMO a 2a (moderate) class of recommendation. Expect more learning and guidance on this therapy by the 2030 update.
Adult advanced life support
The ALS section introduces only a handful of new guidelines, but reinforces or revises several others that many thought might see more of a change this round.
Epinephrine in resuscitation
The top of this list is the recommendation about the use of epinephrine. While epinephrine has been a mainstay of resuscitation for many years, its efficacy has been a hot topic in conference sessions, podcasts and blog posts for the last several years. The 2025 Guidelines keep epinephrine administration as a level 1 (strong) recommendation with no changes to the dosing, timing or intervals.
The use of amiodarone or lidocaine for the treatment of ventricular fibrillation or pulseless ventricular tachycardia unresponsive to defibrillation remains a 2b (weak) recommendation.
I was also interested, but not surprised, to see that the 2025 Guidelines continue to list the routine administration of sodium bicarbonate, calcium, and magnesium in adult cardiac arrest as a COR 3 (no benefit.) Despite the recommendation against the routine use of these drugs, my experience is that many paramedics still take the “well, I have tried everything else” attitude despite the lack of indication for the medication.
The Guidelines also continue to list intravenous access as a level 1 recommendation while instructing providers to move to intraosseous if an IV is not successful or reasonable (COR 2a).
Head-up CPR
Novel approaches to resuscitation including head-up CPR, double sequential defibrillation and vector change defibrillation failed to gain support as well. Head-up CPR was listed as COR 3 (no benefit) and providers are discouraged from implementing it unless part of a formal study. The defibrillation techniques were graded as COR 2b (weak) with the note that usefulness has not been established — clearly an area of additional study.
Cardioversion
One procedure that will be changing is the treatment of regular narrow-complex tachycardia. The starting energy level for electrical cardioversion of adults with atrial fibrillation or atrial flutter should now be 200 joules with incremental increases as needed.
Pediatric advanced life support
Capnography
The most notable update in the pediatric ALS section was the addition of a recommendation that ETCO2 values not be used alone to prompt termination of resuscitation in children. Studies have documented that the possibility of successful outcome remains despite a low ETCO2. The capnography can be used in conjunction with other resuscitation data, the past medical history, and circumstances leading up to the arrest.
Special circumstances
Opioids and naloxone
Previous versions of the AHA Guidelines included the administration of naloxone for suspected opioid abuse, but downplayed it in the setting of cardiac arrest. The 2025 Guidelines seem to give stronger instruction that an opioid antagonist should be given anytime opioid overdose is suspected, but make it clear that it not delay or interfere with standard resuscitation, including CPR and ventilation. This follows other protocols that good airway and ventilation be established before reversing the suspected opioid overdose.
Education and training
The 2025 Guidelines recognize that the way individuals learn has changed and that newer innovative technologies and techniques must be employed. The use of feedback devices during CPR training of healthcare professionals and lay rescuers is a strong recommendation and the Guidelines also refer to a number of other recommended teaching techniques to consider. The use of virtual reality can be used to support training but should not take the place of hands-on CPR skill practice.
Weigh in: What do you think of the new AHA CPR Guidelines?
The 2025 Guidelines cover a broad range of conditions and give treatment recommendations to all levels of lay rescuer and professional healthcare professionals. The highlights I covered here are just the start. Stay tuned to sources like EMS1.com for more details and look forward to learning more in your next refresher trainings.
Stay safe out there.
