Section 1 — Overview
What's New in 2025
Major changes across BLS, ACLS, post-cardiac arrest care, systems, and ethics — first comprehensive update since 2020.
| Topic |
2020 |
2025 Update |
| Chain of Survival |
Separate for in-hospital/out-of-hospital |
New Unified for all ages/settings |
| Trained lay rescuer CPR |
Hands-only preferred |
Changed 30:2 when trained and willing |
| Infant two-finger compression |
Acceptable (single rescuer) |
Eliminated |
| Infant two-thumb technique |
Preferred for 2 rescuers |
Preferred for ALL rescuers |
| FBAO (adult) |
5 back blows OR 5 abdominal thrusts |
5 + 5 alternating until cleared |
| Women & defibrillation |
No specific guidance |
New Clear guidance — no delay for women |
| Opioid algorithm |
Brief mention |
New Standalone algorithm + naloxone emphasis |
| Head-up CPR |
Not recommended |
Not recommended except clinical trials |
| Dual sequential defibrillation |
Not addressed |
Not established — not routine ACLS |
| TTM duration |
≥24 hours |
≥36 hours |
| TTM target |
32–36°C routine hypothermia |
Prevent fever; maintain normothermia |
| Neuroprognostication |
Variable timing |
≥72 hours multimodal post-ROSC/normothermia |
Section 2 — Chain of Survival
Unified Survival Chain
All cardiac arrests — all ages, all settings — now follow a single unified chain of survival model.
🆘
Step 1
Recognition & Activation
Identify + activate emergency response
💓
Step 2
Early High-Quality CPR
100–120/min; depth ≥2 inches
⚡
Step 3
Rapid Defibrillation
AED or defibrillator ASAP
🏥
Step 4
Effective Advanced Care
ACLS: airway, IV, meds
🌡️
Step 5
Post-Cardiac Arrest Care
TTM ≥36h, hemodynamic support
🏁
Step 6
Recovery & Survivorship
Rehab, follow-up, survivorship
💡
Key emphasis 2025: Health equity & addressing CPR disparities — culturally tailored training, addressing barriers to CPR for women (fear of causing injury, inappropriate touch), expanding dispatcher-guided CPR, public access to naloxone & AEDs.
Section 3 — Adult BLS
Basic Life Support — Key Changes
Core CPR mechanics unchanged: rate 100–120/min, depth ≥2 inches, minimize interruptions. Key changes in ventilation recommendations and dispatcher guidance.
Chest Compression Mechanics
100–120
per minute
Compression rate
≤10s
maximum
Interruptions
Firm
surface
Patient position
Ventilation — Key 2025 Change
❌
Untrained / Unwilling
Hands-Only CPR
Still acceptable option
✅
Trained Lay Rescuer
30:2
Compressions:Breaths — when willing and able
👨⚕️
Healthcare Professional
30:2
Compressions:Breaths
🔄
2020 → 2025: Previously, hands-only CPR was preferred for all lay rescuers. Now, trained lay rescuers are specifically advised to provide 30:2 when willing and able.
Dispatcher-Guided CPR
Adult Patient
Hands-Only CPR
Dispatcher instructs compressions only
Child / Infant
Conventional CPR
30:2 — includes rescue breaths
Section 4 — New Algorithm
Opioid Overdose — New 2025 Algorithm
The 2025 guidelines introduce a dedicated standalone algorithm for suspected opioid overdose with expanded naloxone recommendations.
Signs of Opioid Overdose
Unresponsive
Respiratory depression / apnea
Pinpoint pupils (miosis)
Cyanosis
Public / Bystander Response
1
Activate emergency response — call 1669/911 immediately
2
Administer naloxone — IM/SQ preferred by lay rescuers; repeat if no response in 2–5 min
3
Start CPR if no pulse/breathing and trained
4
Recovery position if breathing normally but still unresponsive
5
Repeat naloxone if no response in 2–5 minutes
IM/SQ Preferred (Lay)
0.4–1 mg
Repeat if needed
Auto-Injector
Per device instructions
Also acceptable
Nasal Spray
Per device instructions
Also acceptable
💡
Community naloxone distribution programs are recommended to increase public access and reduce opioid-related mortality. No contraindications in suspected opioid overdose.
Section 5 — FBAO
Foreign Body Airway Obstruction — Updated
Conscious adult/child FBAO
5 back blows OR 5 abdominal thrusts
Conscious adult/child FBAO
5 back blows + 5 abdominal thrusts (alternating) until cleared
CPR + jaw thrust; remove visible objects only
Section 6 — Infant CPR
Major Change: Two-Finger Technique ELIMINATED
The two-finger technique for infant chest compressions has been removed from the 2025 guidelines. Two-thumb encircling hands is now preferred for ALL rescuers.
❌
Two-Finger
ELIMINATED
No longer acceptable
✅
Two-Thumb Encircling
Preferred — ALL Rescuers
Higher coronary perfusion pressure
👋
One-Hand (Heel)
Acceptable
Only if two-thumb not feasible
15:2
ratio
Compressions:Breaths (single or 2 rescuers)
~1.5"
≈4 cm
Compression depth (infant)
100–120
per minute
Compression rate
2 min
CPR first
Then call (if alone rescuer)
Section 7 — Health Equity
Women and Defibrillation — New Guidance
2025 guidelines specifically address barriers that cause delays in CPR and defibrillation for women.
Barriers Identified
• Uncertainty about removing clothing/bras for pad placement
• Misconceptions about causing injury
• Concerns about inappropriate touch
• Fear of harming the patient
• Delayed recognition of cardiac arrest in women
2025 Recommendations
• Remove clothing and undergarments quickly for pad placement
• Defibrillation pads directly on skin
• Standard anterolateral pad placement — no special modification for women
• Train all rescuers to defibrillate women without hesitation
• Public education campaigns targeting CPR for women
⚠️
Do NOT delay defibrillation for women. Standard pad placement (anterolateral) applies. Remove clothing/bras quickly — no special modification needed.
Section 8 — ACLS
Advanced Cardiovascular Life Support
Defibrillation & Energy
| Parameter |
2020 |
2025 Update |
| First shock (biphasic) |
120–200 J |
≥200 J preferred |
| AF/Flutter cardioversion |
100–200 J |
≥200 J first shock |
| Dual sequential defibrillation |
Not addressed |
Not established — not routine ACLS; further study needed |
| Head-up CPR |
Not recommended |
Not recommended except clinical trials |
Vasopressors
Epinephrine
Standard vasopressor — continue every 3–5 minutes
Shockable: Defibrillation FIRST — epinephrine after initial shocks fail
Non-shockable: Consider early initial epinephrine (especially children)
Vasopressin
No advantage over epinephrine
No advantage (alone or in combination) as a substitute for epinephrine in adult cardiac arrest
ℹ️
ECPR: Selective use with formal patient selection criteria. Rapid intra-arrest transport for ECPR may be considered for limited, highly selected adult OHCA patients. Not a universal rescue therapy.
Section 9 — Post-Cardiac Arrest Care
Targeted Temperature Management & Post-ROSC Care
Major paradigm shift: from routine induction of hypothermia → actively prevent fever and maintain sustained normothermia. Duration extended to ≥36 hours.
Target
32–36°C (routine hypothermia)
Approach
Induce and maintain hypothermia
Target
Prevent fever; normothermia
Approach
Continuous temperature monitoring + active control to maintain normothermia
MAP target
≥65 mmHg (unchanged)
Post-ROSC Hemodynamics & Evaluation
94–98%
SpO₂
Avoid hyperoxia
35–45
mmHg
PaCO₂ normocapnia
≥72h
after ROSC
Neuroprognostication timing
Diagnostic Testing
✅ Indicated
• 12-lead ECG — all post-ROSC patients
• Emergency coronary angiography — STEMI, shock, or instability with suspected cardiac cause
• CT/ultrasound — investigate etiology and complications
❌ Not Routinely Indicated
• Coronary angiography for comatose non-STEMI patients — not routinely recommended
• Head-up CPR — not recommended except trials
• Dual sequential defibrillation — not established
Summary — Key Takeaways
Clinical Pearls — CPR 2025
-
1
BLS fundamentals unchanged — 100–120/min compressions, depth ≥2 inches (adults), minimize interruptions to <10 seconds.
-
2
Trained lay rescuers: 30:2 — not hands-only if trained and willing to provide breaths.
-
3
Infant CPR: two-thumb only — two-finger technique eliminated. Two-thumb encircling hands preferred for ALL rescuers.
-
4
FBAO: 5+5 — alternate 5 back blows and 5 abdominal thrusts until object is expelled.
-
5
Women: defibrillate without hesitation — remove clothing quickly, standard anterolateral pad placement, no special modification needed.
-
6
New opioid algorithm — naloxone is critical. Administer immediately (IM/SQ preferred). Community distribution programs recommended.
-
7
Head-up CPR & DSD: NOT routine — not recommended as standard ACLS. Further study needed.
-
8
TTM: ≥36 hours of normothermia — prevent fever actively. Shifted from routine 32–36°C hypothermia induction.
-
9
Post-ROSC MAP ≥65 mmHg — hemodynamic optimization alongside temperature control.
-
10
Neuroprognostication: ≥72 hours — multimodal approach. No single test is definitive. Continuous EEG recommended for children.