ACLS Manual Updates At-A-Glance: 2020 to 2025

Cardiopulmonary Resuscitation (CPR)

Dispatchers should provide chest compression–only CPR instructions to callers for adults with suspected out-of-hospital cardiac arrest (OHCA)

Bystanders should perform chest compressions for all patients in cardiac arrest

Bystanders who are trained, able, and willing to give rescue breaths and chest compressions should do so for all adult patients in cardiac arrest

Bystanders should provide CPR with ventilation for infants and children less than 18 years of age with OHCA

Bystanders who cannot provide rescue breaths as part of CPR for infants and children less than 18 years of age with OHCA, should at least provide chest compressions

For EMS systems, a reasonable alternative to conventional CPR for witnessed shockable OHCA is minimally interrupted cardiac resuscitation

EMS dispatchers should offer dispatcher-assisted CPR instructions for presumed pediatric cardiac arrest

EMS dispatchers should offer dispatcher-assisted CPR instructions for pediatric cardiac arrest when no bystander CPR is in progress

Either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting

There is insufficient evidence to recommend the routine use of extracorporeal CPR for patients with out-of-hospital cardiac arrest in pediatrics, or any cardiac arrest in adults

Extracorporeal CPR may be considered for select pediatric patients with in-hospital cardiac arrest as a rescue therapy when conventional CPR is failing, if it can be implemented competently and efficiently

Laypersons should start CPR for people in presumed cardiac arrest

Continuous arterial blood pressure and end-tidal carbon dioxide measurement can be used to improve the quality of CPR during ACLS resuscitation

After a resuscitation, lay rescuers, EMS providers, and hospital-based healthcare workers may benefit from debriefing to support their mental health and well-being

Airways

If an advanced airway is used, the supraglottic airway should be used for adults with out-of-hospital cardiac arrest where the likelihood of successful tracheal intubation is low. Either device may be used if the likelihood of successful tracheal intubation is high

Expert, experienced providers may place either the supraglottic airway or endotracheal tube in-hospital

Before placement of an advanced airway (supraglottic airway or tracheal tube), EMS providers should perform CPR with cycles of 30 compressions and 2 breaths

EMS providers should perform CPR with 30 compressions to 2 ventilations or continuous chest compressions with positive pressure ventilation (PPV) without pausing chest compressions until a tracheal tube or supraglottic device is placed

Whenever an advanced airway (tracheal tube or supraglottic device) is inserted during CPR, it may be reasonable for providers to perform continuous compressions with PPV delivered without pausing chest compressions

Resuscitation Medications and Access

IV access is preferred over intraosseous (IO) access, but IO can be used for ACLS medication administration during resuscitation if there is no IV access (e.g., cannot be obtained)

Amiodarone or lidocaine may be considered for ventricular fibrillation/pulseless ventricular tachycardia that does not respond to defibrillation. These drugs may be particularly useful for patients with witnessed arrest when the time to drug administration may be shorter

The routine use of magnesium for cardiac arrest is not recommended in adult patients

There is insufficient evidence to support or refute the routine use of lidocaine within the first hour after ROSC

There is insufficient evidence to support or refute the routine use of a β-blocker within the first hour after ROSC

Epinephrine should be administered to patients in cardiac arrest (1 mg every 3 to 5 minutes); high-dose epinephrine is not recommended for routine use in cardiac arrest

Administer epinephrine as soon as feasible for patients with cardiac arrest with a non-shockable rhythm

Administer epinephrine for patients with cardiac arrest with a shockable rhythm after initial defibrillation attempts have failed

Vasopressin may be considered in cardiac arrest but offers no advantage over epinephrine either alone or in combination with epinephrine

Symptomatic bradycardia should be treated with 1.0 mg of atropine IV, when indicated. Past guidelines recommended 0.5 mg.

Defibrillation

Double sequential defibrillation should not be routinely performed during resuscitation

Supplemental Oxygen

Patients in cardiac arrest should receive 100% supplemental oxygen; pulse oximetry measurements are not used to titrate supplemental oxygen

Acute coronary syndrome pulse oximetry range: 90% or higher (i.e., supplement below 90%)

Stroke pulse oximetry range: pulse oximetry 95% to 98% (inclusive)

ROSC and post-cardiac arrest care pulse oximetry range: pulse oximetry 92% to 98% (inclusive)

Post-Cardiac Arrest Care

The initial hospitalization for cardiac arrest should include multidisciplinary assessment and rehabilitation, as needed, prior to discharge

Recovery from cardiac arrest continues long after resuscitation and return of spontaneous circulation (ROSC); patients should receive physical, mental, and social support, as needed

Multimodal neuroprognostication in adult patients after cardiac arrest should be performed (outside the scope of standard ACLS resuscitation)

Resuscitation and Care of Pregnant Women

Cardiac arrest resuscitation and care of pregnant women focuses on the resuscitation of the mother

Early perimortem cesarean delivery may be needed to save the infant and improve the chances of successful resuscitation of the mother

Fetal monitoring should not be used during cardiac arrest in pregnant women

Alert and use a specialized maternal cardiac arrest team when available

Oxygenation and airway management should be prioritized when resuscitating pregnant women are more likely to have hypoxia

Pregnant women who remain comatose after resuscitation from cardiac arrest should receive targeted temperature management and fetal heart rate monitoring with OB/GYN support

Stroke

EMS should check fingerstick glucose in patients with suspected stroke and provide treatment as needed.

In stroke, a CT or MRI of the brain should be performed within 20 minutes of the patient arriving at the hospital.

For ischemic stroke patients who are not candidates for fibrinolytic therapy, consider endovascular thrombectomy. If EVT cannot be performed on-site, eligible patients should be transferred to a facility that provides EVT within 3 hours of arrival at the original hospital

Algorithm Updates

ACLS Post-Cardiac Arrest Care Algorithm

Suspected Opioid Poisoning

Cardiac Arrest in Pregnant Women