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Latest guidelines in detail about ACLS , BLS , PLS all protocols and treatment given in these conditions
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ACLS BLS resuscitation guidelines
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AHA 2024 2025 ACLS BLS PALS guidelines updates latest protocols
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cardiac arrest resuscitation 2025 guidelines
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2025 AHA ACLS algorithm VF VT asystole PEA treatment medications dosages
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2025 AHA BLS guidelines updates opioid naloxone chain of survival pediatric PALS changes
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2025 AHA Guidelines: BLS, ACLS & PALS - Complete Reference
Sources: 2025 AHA Guidelines for CPR & ECC (Circulation 2025;152:suppl 2), Tintinalli's Emergency Medicine, Rosen's Emergency Medicine, European Resuscitation Council (ERC) Guidelines 2025, and PubMed practice guidelines [PMID: 41122884, 41122885, 41122893, 41117573]
PART 1 - KEY 2025 SYSTEM-LEVEL CHANGES (All Protocols)
Single Chain of Survival (NEW 2025)
The 2025 guidelines reverted to one universal Chain of Survival applicable to all cardiac arrests - adult, pediatric, in-hospital, and out-of-hospital:
- Recognition and activation of emergency response
- High-quality CPR (early)
- Rapid defibrillation
- Advanced resuscitation by EMS and healthcare providers
- Post-cardiac arrest care
- Recovery (new link added)
Choking (Foreign Body Airway Obstruction - FBAO) - MAJOR UPDATE
Previously, Heimlich maneuver alone was taught. 2025 now recommends 5+5:
- Adults/Children: 5 back blows (heel of hand between shoulder blades), then 5 abdominal thrusts - alternating until expelled or unresponsive
- Infants: 5 back blows + 5 chest thrusts (NOT abdominal thrusts) - alternating
- Pregnant patients / obese: Use 5 chest thrusts instead of abdominal thrusts
PART 2 - BASIC LIFE SUPPORT (BLS) 2025
BLS for Adults - Healthcare Provider Protocol
Step 1: Scene Safety & Recognition
- Ensure scene safety
- Check responsiveness: tap shoulders, shout "Are you OK?"
- If unresponsive + no breathing or only gasping: activate emergency response system, get AED
Step 2: Pulse Check (max 10 seconds)
- Carotid pulse (adults/children), brachial pulse (infants)
- If no pulse or unsure: START CPR immediately
Step 3: High-Quality CPR
| Parameter | Adult | Child (1yr - puberty) | Infant (<1 yr) |
|---|---|---|---|
| Rate | 100-120/min | 100-120/min | 100-120/min |
| Depth | At least 2 in (5 cm), max 2.4 in (6 cm) | At least 2 in (5 cm) | At least 1.5 in (4 cm) |
| Hand position | 2 hands, lower half of sternum | 1-2 hands, lower half sternum | 2 fingers OR 2 thumb-encircling technique (2-rescuer) |
| Compression:ventilation ratio | 30:2 (1-2 rescuers, no advanced airway) | 30:2 (1 rescuer), 15:2 (2 rescuers) | 30:2 (1 rescuer), 15:2 (2 rescuers) |
| Recoil | Full chest recoil between compressions | Full recoil | Full recoil |
Step 4: Ventilation
- 1 breath every 5-6 seconds when pulse present (adult)
- Visible chest rise without excessive volume
- Avoid hyperventilation (no >10 breaths/min during CPR with advanced airway)
- 100% FiO2 during active CPR
Step 5: Defibrillation with AED
- Attach AED as soon as available
- Minimize pauses - compression fraction must be >60% (aim >80%)
- Resume CPR immediately after shock, 2-minute cycles
- Continue until ALS providers arrive or patient recovers
New 2025 BLS Algorithm Features
- Naloxone now in BLS Algorithm: The healthcare professional BLS algorithm was updated to illustrate the role of opioid antagonists (naloxone) for suspected opioid overdose during respiratory AND cardiac arrest
- Simplified lay-rescuer visual: Emphasizes early EMS activation + AED + chest compressions
- New FBAO algorithm: Back blows first, then abdominal thrusts
- CPR training recommended for children aged 12 and older
Opioid Overdose - New 2025 BLS Guidance
Signs: Slow/absent breathing, choking sounds, drowsiness, pinpoint pupils, cyanosis
New 2025 Recommendations:
- Lay/trained rescuers: Opioid antagonist (naloxone) administration is reasonable for adults/children in cardiac arrest with suspected opioid overdose - provided it does NOT delay standard CPR
- Administer naloxone in addition to standard resuscitation, not instead of
- At discharge: All patients treated for opioid overdose should receive naloxone and instruction on its use
- Naloxone restores airway reflexes and reverses respiratory depression
PART 3 - ADVANCED CARDIAC LIFE SUPPORT (ACLS) 2025
ACLS Framework: Primary + Secondary Survey
Primary Survey (Basic ABCD)
| Component | Action |
|---|---|
| A - Airway | Open airway, check responsiveness |
| B - Breathing | Look, listen, feel; BVM with O2 |
| C - Circulation | Check pulse; start CPR; attach monitor |
| D - Defibrillation | Attach defibrillator, shock if VF/pVT |
Secondary Survey (Advanced ABCD)
| Component | Action |
|---|---|
| A - Advanced Airway | ETT or supraglottic airway; confirm with waveform capnography |
| B - Breathing | Confirm placement; mechanical ventilation; 1 breath/6 sec (10/min) |
| C - Circulation | IV/IO access; rhythm-specific drugs; continuous ECG; consider ECMO |
| D - Differential Diagnosis | Identify and treat reversible causes (H's and T's) |
The Universal ACLS Algorithm (2025)
Step-by-step 2025 Adult Cardiac Arrest Algorithm:
- Start CPR + BVM + O2 + attach monitor/defibrillator
- Rhythm shockable?
If YES (VF/pVT) - Shockable Pathway:
- CPR 2 min → IV/IO access
- Shock (defibrillate)
- CPR 2 min → Epinephrine every 3-5 min
- Shock → CPR 2 min → Amiodarone or Lidocaine (after 3rd shock)
- Treat reversible causes
- Check rhythm every 2 minutes
If NO (Asystole/PEA) - Non-Shockable Pathway:
- CPR 2 min → IV/IO access
- Epinephrine ASAP (every 3-5 min)
- Consider advanced airway + capnography
- Treat reversible causes
- Check rhythm every 2 minutes
Drug Therapy - 2025 ACLS Dosages
Vasopressors
| Drug | Dose | Indication | Notes |
|---|---|---|---|
| Epinephrine | 1 mg IV/IO every 3-5 min | All cardiac arrest rhythms | First-line vasopressor; best if given early (<20 min from arrest onset) |
| Vasopressin | REMOVED from algorithm | - | 2025 confirmed removal; no benefit over epinephrine |
Key 2025 Update on Epinephrine: Multiple studies show epinephrine effectiveness converges with placebo at approximately 20 minutes of pulselessness. After 20 minutes: decreased cerebral blood flow, worse neurological outcome, and increased cardiac ischemia. Administer as early as possible.
Antiarrhythmics (for shock-refractory VF/pVT)
| Drug | Dose | Notes |
|---|---|---|
| Amiodarone | 1st dose: 300 mg IV/IO bolus; 2nd dose: 150 mg | First-choice; give IV preferred over IO (IO may blunt efficacy) |
| Lidocaine | 1st dose: 1-1.5 mg/kg IV/IO; 2nd dose: 0.5-0.75 mg/kg | Acceptable alternative; available in pre-filled syringes |
Give first antiarrhythmic dose after the 3rd shock (evidence suggests earliest possible administration beneficial).
Defibrillation Energy
| Device | Energy |
|---|---|
| Biphasic | Manufacturer recommendation (120-200 J initial); if unknown, use maximum available |
| Monophasic | 360 J |
| Subsequent shocks | Equivalent or escalating energy |
Other Medications by Indication
| Drug | Dose | Indication |
|---|---|---|
| Atropine | 1 mg IV (increased from 0.5 mg) every 3-5 min, max 3 mg | Bradycardia (stable; first-line) |
| Dopamine | 5-20 mcg/kg/min infusion (start 5 mcg/kg/min) | Bradycardia unresponsive to atropine |
| Magnesium sulfate | 1-2 g IV push | Torsades de Pointes (polymorphic VT) |
| Adenosine | 6 mg IV rapid push; repeat 12 mg x2 | Stable SVT |
| Sodium bicarbonate | 1 mEq/kg | Hyperkalemia-induced arrest, TCA overdose, severe acidosis |
| Calcium chloride | 500-1000 mg IV | Hyperkalemia, hypocalcemia, CCB toxicity |
| Naloxone | 0.4-2 mg IV/IM/IN | Opioid overdose (now in BLS AND ACLS algorithms) |
Reversible Causes: The H's and T's
| H's | T's |
|---|---|
| Hypovolemia | Tension pneumothorax |
| Hypoxia | Tamponade (cardiac) |
| Hydrogen ion (acidosis) | Toxins/Tablets (drug overdose) |
| Hypo/Hyperkalemia | Thrombosis, pulmonary (PE) |
| Hypothermia | Thrombosis, coronary (ACS) |
NEW 2025 ACLS Updates
1. Defibrillation - Vector Change & Double Sequential Defibrillation
- Vector Change Defibrillation (NEW 2025): Changing pad placement for adults with persisting VF/pVT after 3+ consecutive shocks - usefulness has NOT been established (insufficient evidence)
- Double Sequential Defibrillation (Updated 2025): Usefulness for adults with refractory VF/pVT also not established - reflect ongoing uncertainty
2. Airway - Updated 2025
- Head and neck trauma: If airway cannot be opened with jaw thrust + airway adjunct, trained rescuers should use head tilt-chin lift (patent airway = priority over spinal precautions)
- Any advanced airway (ETT or supraglottic) is acceptable - outcomes similar
- ET intubation within first 15 minutes of shockable arrest may reduce survival due to compression interruptions - avoid early ETT if it compromises CPR
3. Ventilation - Updated 2025
- Give enough tidal volume to produce visible chest rise
- Avoid hypoventilation (too few breaths or too little volume)
- Continuous waveform capnography: ETCO2 <10 mmHg after 20 min = poor prognosis; ETCO2 >20 mmHg = suggests ROSC; quality compressions should achieve ETCO2 ≥12-15 mmHg
4. Bradycardia Algorithm - New
- A new algorithm for bradycardia in adults with a pulse was added
- Sequence: Atropine → Dopamine/Epinephrine infusion → Transcutaneous pacing (TCP) → Transvenous pacing
5. Tachycardia - Updated
- Unstable wide-complex tachycardia: Synchronized cardioversion is recommended (strong recommendation)
6. Termination of Resuscitation (TOR) - Updated
- In tiered EMS systems (ALS + BLS), the universal TOR rule is now reasonable:
- Arrest NOT witnessed by EMS
- No shock delivered
- No ROSC
- Must rule out hypothermia, toxins, asphyxial causes
Vascular Access Priority (2025)
- IV (peripheral) first - large bore, proximal peripheral vein
- IO - if IV not quickly obtainable (same drug doses as IV)
- Central line - useful for CVP monitoring, but slower for fluid delivery
- Endotracheal route: NO LONGER RECOMMENDED (unreliable absorption)
- Flush each IV drug dose with ≥20 mL normal saline; continue CPR 30-60 seconds after drug delivery before defibrillation
Capnography - Monitoring Standard
- Waveform capnography = most reliable confirmation of ETT placement
- Use continuously throughout resuscitation
- Monitors CPR quality and signals ROSC
- Sudden rise in ETCO2 during CPR = likely ROSC
PART 4 - POST-CARDIAC ARREST CARE (Post-ROSC) 2025
Immediate Post-ROSC Targets
| Parameter | Target |
|---|---|
| SpO2 | 90-98% (avoid hyperoxia) |
| PaO2 | 60-105 mmHg |
| PaCO2 | 35-40 mmHg (avoid hyperventilation) |
| MAP | ≥65 mmHg |
| Temperature | Avoid fever; targeted temperature management |
| Blood glucose | Avoid hypoglycemia AND hyperglycemia |
Temperature Management (Updated 2025)
- Avoid fever is mandatory for all comatose post-arrest patients
- Active cooling considered for specific patients (evidence still evolving from TTM trials)
- Target: normothermia or mild hypothermia per clinical scenario
Coronary Angiography
- STEMI post-ROSC: Immediate PCI indicated regardless of neurological status
- Non-STEMI post-ROSC: Selective PCI based on clinical scenario
Neurological Monitoring
- EEG monitoring for seizures (treat if found)
- CT head for neurological prognostication
- Multimodal prognostication - no single test should determine outcome
Survivorship Care (NEW Recovery Link 2025)
Assessment domains at follow-up:
- Physical function and rehabilitation needs
- Cognitive function and educational support
- Emotional/psychological health
- Family/caregiver support needs
PART 5 - PEDIATRIC LIFE SUPPORT (PALS + PBLS) 2025
Published jointly by AHA and American Academy of Pediatrics (AAP), October 22, 2025, in Circulation and Pediatrics. [PMID: 41122885]
Key Principle: Pediatric Arrest Etiology
Most pediatric arrests are RESPIRATORY or SHOCK-related first, NOT primary cardiac. This fundamentally shapes the approach - early recognition and support of breathing and circulation is the priority.
Pediatric BLS (PBLS) 2025
For Children (1 year to puberty):
- Activate EMS, start CPR, get AED
- Compression depth: at least 2 inches (1/3 AP chest diameter)
- Rate: 100-120/min
- Ratio: 30:2 (1 rescuer), 15:2 (2 healthcare rescuers)
- 2-finger technique OR 2 thumb-encircling (preferred with 2 rescuers for infants)
For Infants (<1 year):
- 2-finger chest compressions OR 2 thumb-encircling technique
- Depth: at least 1.5 inches (4 cm) / 1/3 AP chest diameter
- Ratio: 30:2 (single rescuer), 15:2 (two healthcare rescuers)
Pediatric Cardiac Arrest Algorithm (2025)
Start CPR - BVM + O2 + monitor
Shockable (VF/pVT)?
- YES: Defibrillate → CPR 2 min → IV/IO → Defibrillate → CPR 2 min → Amiodarone or Lidocaine → Treat reversible causes
- NO (Asystole/PEA): CPR 2 min → IV/IO → Epinephrine ASAP → Consider advanced airway → Treat reversible causes
Pediatric Drug Dosing (Weight-Based)
| Drug | Dose | Notes |
|---|---|---|
| Epinephrine | 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL) every 3-5 min | Max single dose 1 mg |
| Amiodarone | 5 mg/kg IV/IO bolus (max 300 mg); repeat x2 | For shock-refractory VF/pVT |
| Lidocaine | 1 mg/kg IV/IO | Alternative antiarrhythmic |
| Adenosine | 0.1 mg/kg (max 6 mg) rapid IV push; repeat 0.2 mg/kg (max 12 mg) | SVT |
| Atropine | 0.02 mg/kg IV/IO (min 0.1 mg, max 0.5 mg/dose) | Bradycardia |
| Magnesium sulfate | 25-50 mg/kg IV/IO (max 2 g) | Torsades, hypomagnesemia |
Defibrillation in Pediatrics
| Dose | Notes |
|---|---|
| Initial: 2 J/kg | First shock |
| Second: 4 J/kg | If first unsuccessful |
| Subsequent: 4-10 J/kg | Max 10 J/kg or adult dose |
2025 PALS-Specific Updates
Airway and Ventilation
- Ventilation and advanced airway strategies updated with new evidence
- BVM remains first-line; LMA and ETT acceptable
Shock Management (PALS)
| Shock Type | Treatment |
|---|---|
| Hypovolemic | Normal saline 10-20 mL/kg IV/IO bolus (reassess frequently) |
| Distributive (septic) | 20 mL/kg NS bolus; vasopressors early (norepinephrine or dopamine) |
| Cardiogenic | Avoid aggressive fluid; consider dobutamine, milrinone |
| Obstructive (tension PTX) | Needle decompression; treat cause |
Arrhythmia Management
- Bradycardia with poor perfusion: CPR if HR <60 with poor perfusion → Epinephrine → Atropine → Pacing
- SVT (stable): Vagal maneuvers → Adenosine → Synchronized cardioversion
- SVT (unstable): Synchronized cardioversion (0.5-1 J/kg; increase to 2 J/kg)
Extracorporeal CPR (ECPR) - 2025
- ECPR (ECMO during CPR) has growing evidence in pediatric in-hospital cardiac arrest
- Consider in centers with ECPR capability for refractory arrest with potentially reversible cause
Myocarditis/Cardiomyopathy - 2025
- Updated guidance for resuscitation in these conditions
- High risk of refractory arrest; ECPR should be considered early
Post-Cardiac Arrest Care in Children (Updated 2025)
| Target | Value |
|---|---|
| Temperature | Avoid fever; TTM at 36-37.5°C for comatose (evidence from THAPCA trial) |
| Oxygenation | SpO2 94-99% (avoid hyperoxia) |
| Blood pressure | ≥5th percentile for age |
| Glucose | Normoglycemia |
| Seizures | EEG monitoring; treat aggressively |
Neurological Prognostication (Post-Arrest Pediatric)
- Multimodal: EEG, MRI, clinical exam, biomarkers
- No single variable should determine prognosis
- Family presence during CPR: Updated guidance - should be offered when possible; associated with improved family psychological outcomes
PART 6 - SPECIAL CIRCUMSTANCES (2025 Updates)
Cardiac Arrest in Pregnancy
- "Resuscitative delivery" replaces "perimortem cesarean delivery" (terminology change 2025)
- Preparation begins at recognition of arrest; goal: delivery by 5 minutes
- Left lateral uterine displacement during CPR
- Dedicated Cardiac Arrest in Pregnancy Algorithm now published
Hypothermic Cardiac Arrest
- Continue CPR; warm patient
- Withhold epinephrine until core temp >30°C (European guideline)
- Up to 3 defibrillation attempts before rewarming to >30°C
- "No one is dead until warm and dead"
Hyperkalemia-Induced Arrest
- Calcium chloride/gluconate
- Sodium bicarbonate
- Insulin + Dextrose
- Dialysis if available
- Standard ACLS otherwise
Massive Transfusion in Trauma Arrest
- Balanced 1:1:1 ratio (RBCs:plasma:platelets) - reduces mortality
SUMMARY TABLE: Key 2025 Changes at a Glance
| Topic | Old (2020) | New (2025) |
|---|---|---|
| Chain of Survival | Separate adult/pediatric chains | Single universal chain |
| Choking | Abdominal thrusts (Heimlich) alone | 5 back blows + 5 abdominal thrusts |
| Naloxone | ACLS only | Now in BLS algorithm too |
| Vasopressin | Optional in algorithm | Removed entirely |
| Atropine first dose | 0.5 mg | 1 mg |
| Head/neck trauma airway | Jaw thrust only | Head tilt-chin lift if jaw thrust fails |
| Double sequential defibrillation | Being studied | Usefulness not established |
| Vector change defibrillation | Not mentioned | New recommendation (evidence insufficient) |
| TOR rule (tiered EMS) | BLS rule | Universal TOR rule now applies |
| Post-arrest care | TTM at 33°C vs 36°C | Avoid fever; normothermia emphasized |
| PALS epinephrine timing | Standard | "ASAP" explicitly emphasized for non-shockable |
| Family presence during CPR | Limited guidance | Should be offered when possible |
| Survivorship | 5-link chain | Recovery added as 6th link |
References:
- Wigginton JG et al. Part 9: Adult Advanced Life Support. Circulation 2025;152(suppl 2):S538-S577. PMID: 41122884
- Del Rios M et al. Part 1: Executive Summary. Circulation 2025;152(suppl 2). PMID: 41122893
- Part 8: Pediatric Advanced Life Support. Circulation/Pediatrics 2025. PMID: 41122885
- Greif R et al. European Resuscitation Council Guidelines 2025. Resuscitation 2025. PMID: 41117573
- Tintinalli's Emergency Medicine, 9th Ed., Ch. 24
- 2025 AHA Highlights PDFThe above covers the complete 2025 AHA BLS, ACLS, and PALS guidelines in detail. Here's a quick orientation:
What's covered above:
- BLS: CPR technique by age group, compression parameters, AED use, new FBAO 5+5 protocol, naloxone now in BLS
- ACLS: Full Primary + Secondary survey, shockable vs non-shockable algorithms, all drug doses and timings, defibrillation energy, airway updates, capnography use, new bradycardia algorithm
- Post-ROSC care: O2/CO2/hemodynamic targets, temperature management, PCI, neurological monitoring
- PALS: Pediatric-specific algorithms, weight-based drug doses, pediatric defibrillation doses, shock management by type, ECPR, post-arrest care in children
- Special situations: Pregnancy, hypothermia, hyperkalemia, trauma
Biggest 2025 changes to remember:
- One universal Chain of Survival (adult + pediatric merged)
- 5 back blows + 5 abdominal thrusts for choking (not Heimlich alone)
- Naloxone added to BLS for opioid overdose
- Vasopressin removed from ACLS algorithm
- Atropine first dose now 1 mg (was 0.5 mg)
- Recovery added as the 6th link in the chain
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