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One of the benefits of Premium membership is the monthly top 10. December 2025 did not disappoint! Here are the ten articles I think will have a big impact on my care. This month, the new AHA resuscitation guidelines dropped, so these are prominently featured in this recap. Note, the heading/title of each article links to the original post.
All my best,
Clay
Written by Clay Smith
1. New AHA BLS 2025 Updates &
Shockingly Sensible: New 2025 AHA Advanced Life Support
a) BLS
Spoon Feed
Basic Life Support (BLS) 2025 guidelines continue to emphasize the core principles of rapid recognition, 100-120/min compression, and early defibrillation. In addition, however, there are several important new AHA recommendations.
Comment
I was especially pleased than an article we covered on back blows first for choking made it into the new BLS guidelines!
Source
Part 7: Adult Basic Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 October. PMID: 41122888.
b) ACLS
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Building on 2020 guidelines, 2025 ALS refines cardioversion in atrial fibrillation, vascular access, imaging, termination of resuscitation (TOR), and more, while also deemphasizing low-yield practices.
Comment
I was very disappointed the AHA did not recommend dual defibrillation for refractory VF. It is clearly better than standard single-device shock. Even AP pad placement (aka “vector change” defib) is superior to standard pad placement. In DOSE VF, neurologically-intact survival with dual defib vs usual was 27% vs 11%, NNT = 7. The AHA ACLS guidelines state, “DSD has not been established.” I respectfully disagree.
Source
Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 October. PMID: 41122884.
2. New AHA 2025 Pediatric BLS—Big Changes for Little Patients & New 2025 AHA PALS—Refining How We Resuscitate
a) Peds BLS
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The 2025 AHA/AAP Pediatric BLS Guidelines introduce major updates: no more 2-finger compressions in infants, immediate AED use with pediatric attenuators, refined foreign-body airway obstruction management, and reaffirmation that breaths matter for pediatric CPR.
Comment
Choking is now also managed with back blows first in children and adolescents. Focus on quality ventilations. No more two-finger compressions; use one hand or two thumbs encircling.
Source
Part 6: Pediatric Basic Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 October. PMID: 41122891.
b) PALS
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The 2025 AHA/AAP Pediatric Advanced Life Support Guidelines refine several core elements of pediatric resuscitation, including shock dosing, airway management, rhythm identification, and post-ROSC care. The updates emphasize physiologic ventilation, minimizing interruption, using ECPR in select cases, and clearer termination guidance, all aimed at improving survival and neurologic outcomes.
Comment
Ventilate well; don’t worry about an ETT if there is any difficulty passing one. Early epinephrine for non-shockable rhythm is recommended.
Source
Part 8: Pediatric Advanced Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 October. PMID: 41122885.
3. 2025 New AHA NRP Updates
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The updated AHA and AAP guidelines on neonatal life support provide the most current, evidence-based recommendations for recognizing and managing newborns who require resuscitation, a time-critical responsibility that has a major impact on survival and neurodevelopmental outcomes.
Comment
Delay cord clamping for 60 seconds if you can. Avoid airway suctioning unless visibly obstructed. As always, ventilation is most important.
Source
Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 October. PMID: 41122887.
4. Phenobarbital vs. Benzos for Alcohol Withdrawal
Spoon Feed
Phenobarbital administration for alcohol withdrawal was associated with lower admission rates, shorter ED length of stay (LOS), and fewer IV medication administrations when compared to benzodiazepines.
Comment
There is an increasing amount of observational data that strongly suggests phenobarbital is superior to benzodiazepines for alcohol withdrawal.
Source
Fewer Admissions, Shorter Stays: Phenobarbital Use for Alcohol Withdrawal in the Emergency Department. Acad Emerg Med. 2025 October. PMID: 41147831.
5. RSI RCT – Finally an Answer to Ketamine vs Etomidate!
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There was no difference in 28-day mortality in critically ill adult patients with ketamine vs. etomidate for rapid sequence induction (RSI), but ketamine increased the need for peri-intubation vasopressor support.
Comment
I have changed my practice based on this. I used etomidate in residency. We then shifted to ketamine. I am shifting back to etomidate in my sick medical patients. The trauma population was not studied in this paper. I suspect we will also switch to etomidate in trauma over time.
Source
RSI Investigators and the Pragmatic Critical Care Research Group. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2025 December. PMID: 41369227.
6. Synthetic Opioids – The Nitazene Wave
Spoon Feed
Nitazenes (a class of synthetic opioids) entered the international drug market in 2019 and are becoming more frequently encountered substance in the ED.
Comment
As an added bonus, I was recently on a podcast called the 260 and covered nitazenes in depth. Here is a handy PDF – Deep Dive on Nitazenes.
Source
Clinical Experiences With the Nitazene Class of Synthetic Opioids: A Cohort Study. Ann Emerg Med. 2025 November. PMID: 40810707.
7. Do We Really Need an Arterial Line?
Spoon Feed
The EVERDAC trial found delayed invasive blood-pressure monitoring to be noninferior to early arterial catheterization in patients with shock in terms of 28-day mortality.
Comment
To be clear, arterial lines still play a role. This suggests they don’t need to be reflexively inserted.
Source
CRICS-TRIGGERSEP F-CRIN Network and the EVERDAC Trial Group. Deferring Arterial Catheterization in Critically Ill Patients with Shock. N Engl J Med. 2025 November. PMID: 41159885.
8. ANDROMEDA-SHOCK-2 – Personalized Septic Shock Resuscitation
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Personalized hemodynamic resuscitation targeting capillary refill time (PHR-CRT) over a 6-hour intervention period demonstrated less need for organ support in patients with septic shock at 28 days.
Comment
I’m not sure I will follow this algorithm fully, but when I’ve optimized MAP, cap refill is poor, and the patient is not clinically improving, I will do a personalized assessment and see if I can give more volume and otherwise improve perfusion. See this deep dive by Sam Rouleau on ANDROMEDA-SHOCK-2 as well.
Source
Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial. JAMA. 2025 October. PMID: 41159835
9. TNK 4.5 to 24 Hours After Stroke – Better Late Than Never?
Spoon Feed
Patients with delayed presentation, 4.5 to 24 hours after onset of ischemic stroke, still had significant benefit from tenecteplase (TNK): NNT = 17, NNH = 72.
Comment
My neurology colleagues are not ready to expand the window yet, but if more studies confirm this, I think they will.
Source
Tenecteplase for Acute Ischemic Stroke at 4.5 to 24 Hours: A Meta-Analysis of Randomized Controlled Trials. Stroke. 2025 October. PMID: 41078125.
10. Penetrating Trauma Transport—EMS, Police, or Private Vehicle?
Spoon Feed
When EMS is not immediately available, transporting adult patients with penetrating injuries in urban settings to trauma centers by police or private vehicle leads to improved survival.
Comment
EMS transport is important, but for most penetrating trauma, rapid definitive surgical management is most important. Opt for the lowest transport time.
Source
Mode of transport and prehospital interventions in urban penetrating trauma: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2025 Sep 19. doi: 10.1097/TA.0000000000004796. Epub ahead of print. PMID: 41114708.
