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EMCrit 412 – 2025 AHA ACLS Guidelines with Shel Cheskes

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Today, Shel Cheskes and I discuss the AHA ACLS 2025 guidelines

Sheldon Cheskes, MD

@DrCheskes

  • Professor, Emergency Medicine, Family and Community Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada 
  • Scientist, Keenan Research Institute, Li Ka Shing Knowledge Institute, St. Michael’s Hospital
  • Medical Director, Regions of Halton and Peel, Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre

Conflict of Interest

Dr. Cheskes has COI: he is on the speakers' bureau of Zoll, received a Zoll Medical Honorarium for CPR Quality and Ventilation during Cardiac Arrest, and received grant funding for studies from Laerdal and Zoll. As such, we will not offer CME for this episode and will make up for it in a subsequent episode.

No CME for this Episode

 

2025 AHA Adult Advanced Life Support Recommendations

The AHA 2025 ACLS Guidelines

  • Use defibrillation (biphasic or monophasic) for VF/pVT or other shockable rhythms in adult cardiac arrest. (COR: 1, LOE: B-NR)
  • Prefer biphasic waveform over monophasic for defibrillation in adult cardiac arrest. (COR: 2a, LOE: B-R)
  • Use a single-shock approach with immediate CPR rather than stacked shocks. (COR: 2a, LOE: B-NR)
  • Choose fixed versus escalating energies per the device’s instructions when shock-refractory rhythms persist. (COR: 2a, LOE: C-LD)
  • If defibrillator can escalate, consider higher energy for second and later shocks after failed initial shock. (COR: 2b, LOE: B-R)
  • If the optimal biphasic energy is unknown, use manufacturer’s first-shock dose; if unknown, maximal energy may be considered. (COR: 2b, LOE: C-LD)
  • Clinical usefulness of artifact‑filtering ECG analysis during compressions is not established. (COR: 2b, LOE: C-LD)
  • Use of VF waveform analysis to guide management is not established. (COR: 2b, LOE: C-LD)
  • Usefulness of changing pad vector after ≥3 shocks is not established. (COR: 2b, LOE: B-R)
  • Usefulness of double sequential defibrillation after ≥3 shocks is not established. (COR: 2b, LOE: B-R)
  • Do not use routine electrical pacing during established cardiac arrest. (COR: 3: No Benefit, LOE: B-R)
  • First attempt IV access for drug delivery in adult cardiac arrest. (COR: 1, LOE: A)
  • IO access is reasonable if IV attempts are unsuccessful or not feasible. (COR: 2a, LOE: A)
  • Central venous access may be considered if IV and IO are unsuccessful or not feasible by trained professionals. (COR: 2b, LOE: C-LD)
  • Give epinephrine during adult cardiac arrest. (COR: 1, LOE: B-R)
  • It is reasonable to give epinephrine 1 mg every 3 to 5 minutes. (COR: 2a, LOE: B-R)
  • In nonshockable rhythms, give epinephrine as soon as feasible. (COR: 2a, LOE: B-NR)
  • In shockable rhythms, give epinephrine after initial defibrillation attempts fail. (COR: 2a, LOE: B-NR)
  • Do not substitute vasopressin alone or with epinephrine for epinephrine. (COR: 3: No Benefit, LOE: B-R)
  • Do not use high‑dose epinephrine routinely. (COR: 3: No Benefit, LOE: B-R)
  • For refractory VF/pVT, amiodarone or lidocaine may be considered. (COR: 2b, LOE: B-R)
  • Use of beta‑blockers, bretylium, procainamide, or sotalol for refractory VF/pVT is of uncertain benefit. (COR: 2b, LOE: C-LD)
  • Use of steroids during arrest is of uncertain benefit. (COR: 2b, LOE: C-LD)
  • Do not administer calcium routinely during arrest. (COR: 3: No Benefit, LOE: B-R)
  • Do not administer sodium bicarbonate routinely during arrest. (COR: 3: No Benefit, LOE: B-R)
  • Do not administer magnesium routinely during arrest. (COR: 3: No Benefit, LOE: B-R)
  • Abrupt ETCO2 rise may be used to detect ROSC during compressions or organized rhythm. (COR: 2b, LOE: B-NR)
  • POCUS use to diagnose reversible causes during arrest is not well established; avoid interruptions. (COR: 2b, LOE: C-LD)
  • POCUS for prognostication during arrest is not well established. (COR: 2b, LOE: C-LD)
  • When available, using maximal feasible FiO2 during CPR may be reasonable. (COR: 2b, LOE: C-LD)
  • Arterial blood gases during CPR have uncertain benefit. (COR: 2b, LOE: C-LD)
  • Using physiologic parameters like arterial pressure or ETCO2 to optimize CPR may be reasonable when feasible. (COR: 2b, LOE: C-LD)
  • Arterial line pressure waveform can be used to detect ROSC during compressions or organized rhythm when present. (COR: 2b, LOE: C-EO)
  • Do not use head‑up CPR outside clinical trials. (COR: 3: No Benefit, LOE: C-LD)
  • When considering TOR, BLS prehospital professionals should use the BLS TOR rule where ALS is unavailable or significantly delayed. (COR: 1, LOE: B-NR)
  • ALS prehospital professionals can use the ALS TOR rule to terminate in the field. (COR: 2a, LOE: B-NR)
  • In tiered EMS systems, using the Universal TOR rule is reasonable. (COR: 2a, LOE: B-NR)
  • In intubated patients, ETCO2 ≤10 mm Hg after 20 minutes may be considered as part of a multimodal decision to stop. (COR: 2b, LOE: C-LD)
  • Providers performing ETI should have frequent experience or retraining. (COR: 1, LOE: B-NR)
  • If airway placement will interrupt compressions, defer until after initial CPR/defib attempts fail or ROSC occurs. (COR: 1, LOE: C-LD)
  • Use continuous waveform capnography with clinical assessment to confirm and monitor ET tube placement. (COR: 1, LOE: C-LD)
  • EMS systems performing prehospital ETI should run ongoing quality improvement and track SGA and ETI success rates. (COR: 1, LOE: C-EO)
  • If using an advanced airway in OHCA with low ETI success or minimal training, SGA is acceptable. (COR: 2a, LOE: B-R)
  • If using an advanced airway in OHCA with high ETI success and good training, SGA or ETI can be used. (COR: 2a, LOE: B-R)
  • In IHCA with expert clinicians, SGA or ETI can be used. (COR: 2a, LOE: B-NR)
  • Either BMV or an advanced airway strategy may be considered during CPR depending on setting and skills. (COR: 2b, LOE: B-R)
  • If an advanced airway is in place, 1 breath every 6 seconds may be reasonable during continuous compressions. (COR: 2b, LOE: C-LD)
  • Synchronized cardioversion for hemodynamically unstable WCT. (COR: 1, LOE: B-NR)
  • Synchronized cardioversion when stable WCT persists despite vagal maneuvers and drugs or when contraindications exist. (COR: 1, LOE: B-NR)
  • IV amiodarone, procainamide, or sotalol may be considered for WCT. (COR: 2b, LOE: B-R)
  • In stable regular monomorphic WCT, IV adenosine may be considered for treatment or diagnosis if etiology uncertain. (COR: 2b, LOE: B-NR)
  • Do not give verapamil or diltiazem for WCT. (COR: 3: Harm, LOE: B-NR)
  • Do not give adenosine for unstable, irregularly irregular, or polymorphic WCT. (COR: 3: Harm, LOE: C-LD)
  • Use vagal maneuvers for acute management of regular NCT. (COR: 1, LOE: B-R)
  • Use adenosine for acute management of regular NCT. (COR: 1, LOE: B-R)
  • Synchronized cardioversion for unstable NCT. (COR: 1, LOE: B-NR)
  • Synchronized cardioversion when stable NCT persists despite vagal maneuvers and drugs or when contraindicated. (COR: 1, LOE: B-NR)
  • IV diltiazem or verapamil can be effective for stable regular NCT. (COR: 2a, LOE: B-R)
  • IV diltiazem or verapamil can be effective for stable regular NCT. (COR: 2a, LOE: C-LD)
  • If hemodynamic instability is due to AF/flutter with RVR, perform immediate synchronized cardioversion. (COR: 1, LOE: C-LD)
  • In ACS with compromise, ischemia, or inadequate control, urgent cardioversion is recommended. (COR: 1, LOE: C-LD)
  • For AF cardioversion with biphasic defibrillators, starting energy at least 200 J is reasonable, then escalate as needed. (COR: 2a, LOE: B-R)
  • Usefulness of double synchronized cardioversion as initial strategy is uncertain. (COR: 2b, LOE: B-R)
  • For flutter, 200 J initial energy may be reasonable, escalating if needed. (COR: 2b, LOE: C-LD)
  • Usefulness of double synchronized cardioversion as rescue for shock‑refractory AF is uncertain. (COR: 2b, LOE: C-LD)
  • Use IV beta‑blocker or nondihydropyridine calcium channel blocker for acute rate control without preexcitation. (COR: 1, LOE: B-NR)
  • IV amiodarone can be useful for rate control in critically ill patients without preexcitation. (COR: 2a, LOE: B-NR)
  • In preexcited AF/flutter, avoid digoxin, nondihydropyridine calcium channel blockers, beta‑blockers, and IV amiodarone. (COR: 3: Harm, LOE: C-LD)
  • Avoid nondihydropyridine calcium channel blockers and IV beta‑blockers in LV systolic dysfunction with decompensated HF. (COR: 3: Harm, LOE: C-EO)

 

 

Vector Change and DSED

Synopsis

Combined with CPR, successful defibrillation is essential to survival from cardiac arrest caused by VF/VT.1,2 Defibrillation delivers shock energy (joules), creating a current across the thorax from pad-to-pad.3 Its success is influenced by a variety of factors independent of energy setting, including the electrical resistance of tissues encountered (typically highest at the skin-pad interface) that can dramatically reduce current delivery,4–7 pad positions (and resulting shock “vector”) that encompass the heart anatomically8–11 and concomitant high quality CPR. When these are all properly managed, biphasic shock can be highly effective (>75% success) in terminating VF/pVT.12,13
“Shock-resistant” and “shock-refractory” are commonly used to describe VF/pVT that continues to be seen on rhythm checks after repeated shocks. In some cases this is due to true failure of shock to terminate VF/pVT, resulting in ongoing, incessant VF/pVT. Causes of such shock failure can be related to correctable deficiencies in defibrillation technique that are best addressed before employing alternate shock strategies such as pad repositioning (vector change) or double sequential defibrillation (DSD). Conversely, evidence indicates a far more common mechanism for VF/pVT that continues to be seen on post-shock rhythm checks (≈80% of instances) is not due to shock failure, but rather to VF/pVT’s recurrence following successful termination by shock, an event that is obscured by the ensuing period of CPR. When CPR is later paused for rhythm/pulse checks, VF/pVT then seen is attributed to shock failure rather than to its recurrence after successful termination, which is more often the actual case.12,14,15 This distinction is important since recurrent VF/pVT may be better remedied by post-shock rhythm stabilization therapy rather than altering an already successful defibrillation technique. Thus labels like “shock-refractory” can be misleading when they conflate different mechanisms for post-shock VF/pVT, for which different treatment strategies may be required. Accordingly, we propose using “persisting VF/pVT” in these guidelines for patients who remain in VF/pVT arrest after ≥3 consecutive shocks, when its actual mechanism (incessant VF/pVT due to true shock failure vs recurrent VF/pVT following successful termination by shock) is not known with certainty.

Recommendation-Specific Supportive Text

1 and 2.
Prior systematic reviews of low-quality evidence have not reported benefit from DSD for persisting VF.16–20 Defibrillator pad relocation, called vector change (VC), an inherent feature of DSD, was evaluated in only one trial as a stand-alone measure. That trial (DOSE-VF), compared standard defibrillation, VC, and DSD in patients with cardiac arrest in whom VF continued to be seen on rhythm checks after 3 standard shocks. It found significant improvement in survival at hospital discharge with VC and DSD compared to standard defibrillation by intention-to-treat, but notably not when trial findings were analyzed by the treatment strategy patients actually received.21 Furthermore, in a secondary exploratory analysis a significant survival benefit from DSD was only observed in the 17% of study patients in whom VF was incessant, and not in the vast majority (83%) of patients in whom VF recurred after a successful shock.22 The interval between each sequential “double” shock required for successfully terminating VF has also been shown experimentally23,24 and demonstrated in DOSE-VF itself25 to require a level of precision (separated by milliseconds) unlikely to be consistently achievable by manual activation of two defibrillators. Based on its review, ILCOR’s 2023 International Consensus on CPR and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) judged the overall supportive evidence as relatively weak when issuing “may be considered” recommendations for VC and DSD.26 The adoption of VC or DSD into routine clinical practice for persisting VF/pVT (by whatever mechanism) thus requires further investigation, given its diagnostic and technological requirements.27 These include technologies that can reliably distinguish recurrent from incessant post-shock VF during ongoing CPR,28 provide the precise timing interval needed between shocks, and best direct if, how, when, and in whom such a strategy may be applicable.

ILCOR

Double Sequential Defibrillation for Cardiac Arrest With Refractory Shockable Rhythm (ALS 3106, SysRev 2023)
The use of double sequential external defibrillation for cardiac arrest with refractory shockable rhythm was initially addressed by a 2020 SysRev22 and the SysRev was updated for the 2023 CoSTR summary.23
Population, Intervention, Comparator, Outcome, and Time Frame
Population: Adults in any setting (in-hospital or outof-hospital) with cardiac arrest and a shockable ventricular fibrillation (VF)/ pulseless ventricular tachycardia (pVT) cardiac arrest rhythm
Intervention: double sequential external defibrillation
Comparator: Standard defibrillation strategy
Outcomes:
–Critical: Survival with favorable neurological outcome at dis-charge, 30 days, 60 days, 90 days, 180 days, or 1 year; sur-vival at discharge, 30 days, 60 days, 90 days, 180 days, or 1 year
– Important: ROSC or survival to hospital admission
Other: Termination of VF/pVT
Time frame: February 28, 2020, to November 7, 2022
Treatment Recommendations (2023)
We suggest that a double sequential defibrillation strategy (weak rec-ommendation, low-certainty evidence) or a vector change defibrillation strategy (weak recommendation, very low–certainty evidence) may be considered for adults with cardiac arrest who remain in VF or pVT after 3 or more consecutive shocks.
If a double sequential defibrillation strategy is used, we suggest an approach similar to that in the available trial, with a single operator activating the defibrillators in sequence (good practice statement).

From BLS – Mechanical CPR

Several large RCTs demonstrated no improvement in survival with the use of mechanical CPR devices.12-16 This is further supported by a recent ILCOR systematic review.17 The Prehospital Randomised Assessment of a Mechanical Compression Device in Out-of-Hospital Cardiac Arrest (PARAMEDIC) trial found no survival benefit at 30 days.13,18 and worse neurological outcome at 30 days, 3 months, and 12 months with the use of mechanical devices.13,19,20 However, neurologic outcomes at 3 months and 12 months were significantly limited by loss to follow-up in greater than 40% of patients.20 A secondary analysis of the primary study population in the AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) trial found decreased 4-hour survival with mechanical CPR, possibly associated with a delayed time to first shock, and the study was terminated due to potential harm in the mechanical group.12 Two small observational studies showed increased rib fractures and sternal fractures with mechanical CPR use.21,22 However, this finding has not been replicated in the published RCTs.13,19,20

Outcomes from this study (miscited in the guidelines) [Post-admission outcomes of participants in the PARAMEDIC trial: A cluster randomised trial of mechanical or manual chest compressions. Ji, C. et al. Resuscitation 2017;118:82]–their conclusion: There were no clinically important differences identified in outcomes at long term follow-up between those allocated to the mechanical chest compression compared to those receiving manual chest compression.

Load Distributing Band Devices

Do not use auto-pulse devices:

joc60065

ILCOR Guidelines discuss only the Auto-Pulse amongst the negative trials

ILCOR Mech CPR

Cochrane SR

Cochrane Review

 

Piston Devices

Two large (4471 and 2549 patients) showed no difference in neurological outcome at hospital discharge, 3 months or 6 months [PARAMEDIC Lancet 2015;385:947–55 & LINC JAMA 2014;311:53–61]. Four RCTs for survival [see ILCOR guidelines]

 

Don't Pace Asystole

 

Vasopressor Management

Epi after initial defib has failed

“However, there have been no clinical trials demonstrating an advantage to using vasopressin alone or vasopressin in addition epinephrine over standard-dose epinephrine alone.” ?????

Other Meds

No Mag, Sodium Bicarb, or Calcium unless there is a clear indication

 

CPR Adjuncts

A retrospective study from the AHA’s Get With the Guidelines-Resuscitation found the use of ETCO2 or diastolic blood pressure monitoring during CPR was associated with increased rate of ROSC.39 ETCO2 values reflect pulmonary circulation and cardiac output1,2 and are positively correlated with increased compression depth40–42 and release velocity.40,41 Multiple systematic reviews have found numeric ETCO2 measures to be a predictor of ROSC.4,43 An ETCO2 less than 10 mm Hg is generally associated with poor outcomes, whereas values above 10 mm Hg, and ideally above 20 mm Hg, are associated with increased rates of ROSC.43 The combination of the association of higher ETCO2 with ROSC and the findings that CPR quality can increase ETCO2 suggests that targeting compressions to a value of at least 10 mm Hg, and ideally 20 mm Hg or greater, may indicate mechanically adequate technique. Other factors known to impact ETCO2 values need to be considered, including minute ventilation, drug administration, airway management strategies, and cardiac arrest etiology. ETCO2 monitoring is most reliable when measured through an endotracheal tube, but it can also be used with a supraglottic airway or bag-mask ventilation with unclear utility. When an invasive arterial line is in place, arterial diastolic pressure can approximate coronary perfusion pressure and myocardial perfusion during CPR.44 The use of diastolic blood pressure monitoring during cardiac arrest is associated with higher ROSC, but there are inadequate adult data to suggest any specific pressure in adults.

  1. Sutton RM, French B, Meaney PA, Topjian AA, Parshuram CS, Edelson DP, Schexnayder S, Abella BS, Merchant RM, Bembea M, et al; American Heart Association's Get With The Guidelines–Resuscitation Investigators. Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study. Resuscitation. 2016;106:76–82. doi: 10.1016/j.resuscitation.2016.06.018

Termination of Resuscitative Measures

 

Advanced Airway

Wide Complex Tachycardia

No adenosine for weird, wide, wapid

 

Polymorphic Ventricular Tachycardia

 

Regular Narrow-Complex Tachycardia

Avoid CCBs in reduced EF / systolic heart failure

 

Electrical Therapies for A-Fib/A-Flutter

Finally–shock at highest energy for cardioversion

 

Drug Therapies for A-Fib/A-Flutter

 

Bradycardia

Symptomatic bradycardia may be caused by a number of potentially reversible or treatable causes, including myocardial ischemia, hypoxemia, hypothyroidism, infections, structural heart disease, increased vagal tone, metabolic derangement, electrolyte abnormalities, or medications/toxins.

 

 

 

Hyperkalemia

Pregnancy

Where is Hypoglycemia??

 

 

Additional New Information

 

More on EMCrit

 

Additional Resources

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Scott Weingart, MD FCCM
Latest posts by Scott Weingart, MD FCCM (see all)

Cite this post as:

Scott Weingart, MD FCCM. EMCrit 412 – 2025 AHA ACLS Guidelines with Shel Cheskes. EMCrit Blog. Published on November 15, 2025. Accessed on December 9th 2025. Available at [https://emcrit.org/emcrit/2025-aha-acls-guidelines/ ].

Financial Disclosures:

The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.

CME Review

Original Release: November 15, 2025
Date of Most Recent Review: November 15, 2025
Termination Date: Aug 1, 2028

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Chris Holthaus
Chris Holthaus
13 days ago

Hi Scott and Shel, great coverage! I might have missed this and apologies if it was alluded to or mentioned, but do you think there would be any benefit/utility/harm for first pass defib to do single set of AP pads with biphasic charging to say 360J or 400J (would be dependent on AED max limits if they can be dialed past 200J)? Your discussions on earlier defib being better as well as the concept of more Joules and AP positioning along with dual sequential approach had me wondering if that might be helpful as well or a beneficial compromise if… Read more »

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Scott Weingart, MD FCCM
Scott Weingart, MD FCCM
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Reply to  Chris Holthaus
12 days ago

Chris,
I think we discussed this on the first all things defib podcast. Higher energy didn’t seem to result in benefit beyond the 200 J biphasic.

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