AHA BLS and ACLS 2025 Guidelines Update:

The AHA 2025 BLS and ACLS guidelines introduce updated CPR sequences, naloxone integration for opioid emergencies, and a unified chain of survival. Nurses and providers benefit from streamlined algorithms, role clarity, and evidence-based resuscitation practices.

Introduction

The American Heart Association (AHA) guidelines for Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) are universally recognised as the gold standard for resuscitation care. These evidence-based protocols guide healthcare providers, educators, and institutions globally in delivering high-quality emergency cardiovascular care. In 2025, the AHA has released significant updates to both BLS and ACLS guidelines, reflecting the latest research and clinical experience. The 2025 update is especially relevant, given the evolving landscape of resuscitation science, emerging technologies, and the lessons learned from recent global health challenges.

Background

Since its inception in the 1960s, the AHA has played a pivotal role in standardising resuscitation protocols. The first formal guidelines were published in 1974, and since then, the association has revised its recommendations every five years, incorporating new scientific evidence and feedback from the field.

The periodic revision process ensures that the guidelines remain current, reflecting advances in medical technology, pharmacology, and systems of care. Previous updates—including those in 2010, 2015, and 2020—have introduced major changes such as the emphasis on high-quality chest compressions, the integration of automated external defibrillators (AEDs), and the expansion of post-cardiac arrest care.

The 2025 update continues this tradition, addressing gaps identified in recent years and responding to the dynamic nature of clinical practice.

Summary of Major Changes in the 2025 Guidelines

The 2025 AHA guidelines for BLS and ACLS encompass several key updates, reflecting robust evidence and expert consensus. Major changes include:

• Refined CPR Techniques: Adjustments to compression depth, rate, and sequence to optimise efficacy.
• Airway Management Enhancements: New recommendations for airway devices and advanced techniques.
• Defibrillation Protocols: Updated timing and device use, including expanded indications for certain populations.
• Pediatric Resuscitation: Specific modifications to paediatric BLS and ACLS algorithms.
• ACLS Algorithm Modifications: Streamlined decision pathways and medication protocols.
• Post-Resuscitation Care: Greater emphasis on comprehensive neurological assessment and targeted temperature management.
• Special Scenarios: New guidance for opioid overdose, COVID-19, and other emerging issues.

These changes are grounded in systematic reviews, meta-analyses, and multicentric clinical studies, ensuring that recommendations are both practical and scientifically sound.

Basic Life Support (BLS) 2025 Updates

CPR Technique: Depth, Rate, and Sequence

One of the most notable updates in BLS is the adjustment of recommended chest compression depth and rate. For adults, compressions should be delivered at a depth of 5–6 cm (2–2.4 inches) and at a rate of 100–120 per minute, as evidence suggests this range maximises perfusion without causing excessive harm. The “Push Hard, Push Fast” mantra remains, but the 2025 guidelines further stress the importance of minimal interruptions and immediate resumption of compressions after defibrillation or airway intervention.

In addition, the sequence of actions in cardiac arrest has been clarified: rescuers should initiate chest compressions before attempting airway management or ventilations, unless advanced personnel are immediately present. This change aims to reduce delays in perfusion and improve survival rates.

Airway Management: Devices and Techniques

The guidelines now recommend the use of supraglottic airway devices (SGAs) as first-line options for trained providers, citing improved outcomes in pre-hospital and in-hospital settings. The role of bag-valve mask ventilation remains central for lay rescuers and basic providers, while advanced airway placement (endotracheal intubation) is reserved for those with specific expertise, given its complexity and potential for complications.

Moreover, the guidelines emphasise continuous waveform capnography for confirming and monitoring advanced airway placement, given its reliability and utility in assessing resuscitation quality.

Defibrillation: Protocols and Devices

Early and effective defibrillation continues to be a cornerstone of BLS. The 2025 update underscores the importance of minimising “no-flow” time—periods without chest compressions—when using AEDs. Rescuers are advised to resume compressions immediately after shock delivery and to avoid unnecessary pauses for rhythm analysis. The guidelines also expand indications for AED use in paediatric patients and recommend paediatric pads for children under 8 years of age.

Pediatric Considerations

Paediatric BLS has been updated to reflect new evidence on compression depth (one-third the anterior-posterior diameter of the chest) and rate (100–120 per minute). The two-thumb encircling technique is preferred for infants, with a focus on high-quality compressions and prompt defibrillation when indicated. The need for early recognition and activation of emergency response is also emphasised, particularly in school and community settings.

Advanced Cardiovascular Life Support (ACLS) 2025 Updates

Algorithm Modifications: Streamlining Care

The ACLS algorithms have been streamlined to enhance decision-making and reduce cognitive overload during resuscitation. The key changes include:

• Unified Cardiac Arrest Algorithm: A single, simplified pathway for adult cardiac arrest, integrating shockable and non-shockable rhythms.
• Emphasis on Team Dynamics: Explicit roles and responsibilities for resuscitation team members, including the use of checklists and closed-loop communication.
• Early Identification of Reversible Causes: Enhanced focus on the “Hs and Ts” (hypoxia, hypovolaemia, hydrogen ion [acidosis], hypo/hyperkalaemia, hypothermia, toxins, tamponade, tension pneumothorax, thrombosis) with point-of-care diagnostics.

Medication Updates

The 2025 guidelines revise recommendations for several medications:

• Epinephrine: Early administration (within the first five minutes) for non-shockable rhythms, with caution against excessive dosing.
• Amiodarone and Lidocaine: Both are acceptable for refractory ventricular fibrillation/pulseless ventricular tachycardia, with dosing adjustments for paediatric and elderly populations.
• Vasopressin: No longer recommended for routine use due to lack of demonstrable benefit.
• Calcium, Magnesium, and Sodium Bicarbonate: Reserved for specific indications, such as hyperkalaemia or tricyclic antidepressant overdose.

The guidelines also stress medication safety, advocating for pre-prepared syringes and colour-coded labelling to prevent errors during high-stress scenarios.

Post-Resuscitation Care: Neurological and Cardiac Support

Post-resuscitation management now features prominently in ACLS, including:

• Targeted Temperature Management (TTM): Maintaining a temperature between 32–36°C for comatose adults after cardiac arrest.
• Early Neurological Assessment: Use of validated scoring systems and imaging modalities to guide prognostication.
• Coronary Intervention: Immediate evaluation for percutaneous coronary intervention (PCI) in patients with STEMI or suspected cardiac origin.
• Organ Support: Multidisciplinary approach to ventilation, haemodynamics, and metabolic management.

Special Scenarios: Opioid Overdose, COVID-19, and More

The 2025 guidelines address a range of special circumstances:

• Opioid Overdose: Naloxone administration for suspected opioid-related respiratory depression, with concurrent BLS/ACLS interventions.
• COVID-19 and Highly Infectious Diseases: Enhanced personal protective equipment (PPE), prioritisation of staff safety, and airway management strategies to minimise aerosolisation.
• Pregnancy, Trauma, and Drowning: Algorithm modifications and specific recommendations for these high-risk populations.

Clinical Implications:

The 2025 update will have a pronounced impact on clinical practice, including:

• Emergency Response: Pre-hospital providers must update protocols to reflect new compression techniques, airway management, and AED use.
• Hospital Protocols: Institutions should revise resuscitation policies, training curricula, and documentation procedures.
• Interdisciplinary Training: Emphasis on team-based scenarios, communication, and role clarity during resuscitation events.

Healthcare providers are expected to stay current with guideline changes, and many regulatory bodies will require documented competency in the new protocols for licensure and credentialing.

Practical Recommendations:

For Healthcare Providers

1. Review the 2025 Guidelines: Attend official update courses and read the AHA’s summary documents.
2. Practise New Techniques: Participate in simulation-based training, focusing on revised algorithms and medication protocols.
3. Document Competency: Maintain updated certifications and evidence of proficiency in BLS and ACLS.

For Educators

1. Update Curriculum: Integrate the 2025 changes into teaching materials, simulation scenarios, and assessments.
2. Emphasise Teamwork: Foster communication and leadership skills in resuscitation training.
3. Promote Continuing Education: Encourage frequent refresher courses and peer-to-peer learning.

For Institutions

1. Revise Policies: Ensure that institutional protocols align with the latest AHA recommendations.
2. Invest in Equipment: Upgrade AEDs, airway devices, and medication safety systems as per new standards.
3. Monitor Outcomes: Track resuscitation metrics and patient outcomes to evaluate guideline implementation.

Challenges and Opportunities:

Implementing new guidelines often presents challenges. Common barriers include resource limitations, resistance to change, and variability in provider experience. Technology integration—such as electronic checklists, real-time feedback devices, and virtual training platforms—offers solutions to many of these challenges. The 2025 guidelines explicitly encourage the adoption of innovations that enhance compliance and performance.

Looking forward, future updates may incorporate artificial intelligence for rhythm analysis, wearable devices for real-time monitoring, and expanded telemedicine applications. The AHA continues to support ongoing research and welcomes feedback from the global resuscitation community.

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

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