ACLS Manual Updates At-A-Glance: 2020 to 2025
Current Recommendations – Guideline Updates |
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 |