Written by Ketan Patel
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Building on 2020 guidelines, 2025 ALS refines cardioversion in atrial fibrillation (AF), vascular access, imaging, termination of resuscitation (TOR), and more, while also deemphasizing low-yield practices.
2025 ALS updates EM docs will actually use
The 2025 AHA guidelines synthesize evidence from systematic reviews, RCTs, registries, and expert consensus, giving us updated guidelines with class of recommendation (COR)/ level of evidence (LOE) grading.
Key Updates and Highlights (COR in parentheses):
- Go big for a-fib/a-flutter: Immediate shock when these patients are unstable (1), and start at ≥200 J biphasic (2b).
- Persistent ventricular fibrillation (VF): Usefulness of double sequential and vector change defibrillation remains unestablished in refractory VF (2b). *Read my editor’s note ~Clay
- Head-up CPR: explicitly discouraged outside of trials! (3, no benefit)
- Access hierarchy, out with the patriarchy: IV first line (1); IO reasonable if IV delayed (2a); endotracheal drug administration is out.
- Polymorphic VT: treated as always unstable—immediate defibrillation prioritized (1).
- Master of the domain: supraglottic vs. endotracheal intubation should be guided by local success rates/training; continuous waveform capnography still king of confirmation (1).
- To be or… actually, the rest of the 2b recommendations: POCUS can be used in skilled hands, but without interruption of resuscitation efforts. End-tidal CO2 and arterial lines can help guide resuscitation and may provide feedback on return of spontaneous circulation. No specific end-tidal CO2 should be used for termination of resuscitation, but it can be part of a multimodal approach.
Many recommendations rely on low-certainty or observational data and heterogeneous systems, and key questions remain unresolved (ideal energy strategies, IO site selection, intra-arrest prognostication, DSD/vector-change candidacy).
How will this change my practice?
New guidelines reaffirm that ALS should focus on good-quality, team-based resuscitations, high-quality CPR, and early defibrillation, while considering both flexibility and feasibility for airway and access interventions. I’ll keep certain “Hail Mary” techniques in my back pocket, particularly for refractory ventricular arrests, but I’ll continue teaching primarily about resuscitative adjunct usage as a supplement to the core principles of a good resuscitation.
*Editor’s note: Totally disagree with AHA on DSD. Dual defibrillation is clearly better for refractory VT/VF; vector change less so; but both are superior to standard defib/standard pad placement. Neuro-intact survival, DSD vs usual: 27% vs 11%, NNT = 7. AHA states, “DSD has not been established.” That’s just incorrect. ~Clay Smith
Source
Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 Oct 21;152(16_suppl_2):S538-S577. doi: 10.1161/CIR.0000000000001376. Epub 2025 Oct 22. PMID: 41122884.
