Distinction. Precision.
Resuscitation Excellence.

A single Chain of Survival is intended to apply to adult and pediatric in-hospital and out-of-hospital cardiac arrest. Creating this singular chain acknowledges that prevention and preparedness can both avoid the need for and optimize resuscitation, and that survivorship and recovery are part of the continuum.

Implementation of safety huddles to improve situational awareness around high-risk hospitalized patients can be effective in reducing cardiac arrest rates. The recommendation is supported by two multicenter observational quality-improvement projects in pediatric cardiac and general ICUs.

Pediatric and adult recommendations for early warning systems and rapid response or medical emergency teams have also been combined into unified guidance.

Public policies should allow for possession, use, and immunity from civil and criminal liability for good-faith administration of naloxone by lay rescuers. Naloxone distribution programs can be beneficial to increase availability among lay rescuers and decrease mortality from opioid-related overdose.

Telecommunicators are now provided with age-specific recommendations:

• Adults — guide lay rescuers to use Hands-Only CPR.
• Children — guide lay rescuers to use conventional CPR, including breaths.

The "No-No-Go" framework is reiterated as an effective method for recognizing OHCA by phone.

Incorporating both immediate ("hot") and delayed ("cold") debriefing is reasonable. Neither has been proved superior, but each may identify different opportunities for system improvement, and using both may offer advantages.

Out-of-hospital: It can be beneficial to have an ALS-level clinician present during the resuscitation of a suspected OHCA, and EMS teams should be sized to allow discretely assigned roles.

In-hospital: Code teams should comprise ALS-trained members with clearly defined roles, diverse expertise, and adequate training that incorporates simulation.

Prioritizing on-scene resuscitation focused on achieving sustained ROSC before initiation of transport can be beneficial for most adult and pediatric OHCA in the absence of special circumstances.

EMS systems should also be prepared to perform termination of resuscitation on scene, with training in compassionate death notification — both to provide compassionate care and to limit clinician burnout.

ECPR is resource-intensive and requires specialized, highly trained teams. Programs should:

• Develop and frequently reassess patient-selection criteria to maximize survival, ensure equitable access, and limit futility.
• Employ clinicians experienced in percutaneous cannulation.
• Take a regionalized approach to optimize outcomes and resource utilization.

Rapid intra-arrest transport for ECPR may be considered for limited, highly selected adult OHCA patients.

Recovery and long-term functional outcomes of cardiac arrest survivors are likely to benefit from the use of integrated systems that assess patients before discharge, reassess their needs after discharge, and address those needs on an ongoing basis during recovery — supported by a multidisciplinary team that spans in- and out-of-hospital providers.

For term newborns who do not require immediate resuscitation, deferred cord clamping for at least 60 seconds can be beneficial compared with immediate clamping.

For preterm newborns under 37 weeks who do not require immediate resuscitation, deferred cord clamping of at least 60 seconds is recommended over immediate clamping — with reduced mortality in this population.

For non-vigorous term and late-preterm infants at 35 weeks or more gestational age, intact cord milking may be reasonable when compared with immediate cord clamping. A large RCT reported decreases in rates of cardiorespiratory support, moderate-to-severe hypoxic-ischemic encephalopathy, and the use of therapeutic hypothermia.

Initial peak inflation pressures of 20 to 30 cm H₂O are reasonable, with adjustment as effective ventilation is achieved.

Providing ventilation at a rate of 30 to 60 per minute is reasonable, with adequate tidal-volume delivery and effective carbon-dioxide clearance.

Video laryngoscopy can be useful for newborns who require endotracheal intubation. A meta-analysis of 6 RCTs showed increased intubation success compared with traditional laryngoscopy, which remains a reasonable alternative.

For newborns at 34 0/7 weeks or more, a laryngeal mask is reasonable as an alternative to endotracheal intubation when face-mask ventilation is unsuccessful.

It may also be reasonable as the primary ventilation interface instead of a face mask in this population — meta-analysis showed decreased probability of device failure, lower intubation rates, and shorter ventilation times.

A pulse oximeter should be placed as soon as possible for newborns receiving respiratory support or supplemental oxygen. The updated SpO₂ target table starts at 2 minutes because deferred cord clamping for 60 seconds or more means a 1-minute saturation will not routinely be obtained. ECG is recommended before chest compressions.

For preterm newborns born at less than 32 weeks gestational age receiving respiratory support at birth, it may be reasonable to begin with 30% to 100% oxygen, titrated down as targets are achieved.

It may be reasonable to compress over the lower third of the sternum, taking care to stay above the xiphoid process. Autopsy studies found midsternum compressions were not associated with liver rupture, while compressions on the xiphoid were associated with hepatic injury.

Switching compressors every 2 to 5 minutes — including during heart-rate assessment — may be reasonable to preserve compression quality.

For infants and children in cardiac arrest, interruptions in CPR should be minimized and pauses in chest compressions should be less than 10 seconds. Increased frequency and duration of pauses are significantly associated with a lower probability of achieving ROSC.

For infants, rescuers should compress the sternum using either the heel-of-one-hand technique or the two-thumb–encircling-hands technique. If the rescuer cannot physically encircle the chest, the heel-of-one-hand technique is recommended.

The long-used two-finger technique for infant CPR is no longer recommended. When studied in registry data, the two-finger technique was rarely used and produced no chest-compression segments compliant with AHA guidelines.

For children with severe foreign-body airway obstruction, repeated cycles of 5 back blows alternated with 5 abdominal thrusts should be performed until the object is expelled or the child becomes unresponsive. To create consistency for instructional purposes, management now starts with back blows.

For infants with severe FBAO, repeated cycles of 5 back blows alternated with 5 chest thrusts (heel-of-one-hand) should be performed until the object is expelled or the infant becomes unresponsive. Abdominal thrusts are not recommended in infants because of the risk of abdominal organ injury.

For infants and children in cardiac arrest with an initial non-shockable rhythm, it is reasonable to administer the initial dose of epinephrine as early as possible. Time to first epinephrine of less than 3 minutes has been associated with the highest rates of favorable outcome.

For patients with an invasive airway in place, end-tidal CO₂ monitoring may be considered as one indicator of CPR quality. ETCO₂ values of 20 mm Hg or greater during pediatric in-hospital CPR have been associated with increased odds of ROSC and survival to discharge.

However, a specific ETCO₂ cutoff value alone should not be used to decide to end resuscitation — survival has been observed in patients with average ETCO₂ less than 20 mm Hg.

With continuous invasive arterial pressure monitoring in place, it may be reasonable to target a diastolic blood pressure of at least 25 mm Hg in infants and at least 30 mm Hg in children 1 year of age or older. Improved rates of survival with favorable neurological outcome have been observed at these thresholds.

When SVT with cardiopulmonary compromise is unresponsive to vagal maneuvers, adenosine, and synchronized cardioversion — and expert consultation is unavailable — intravenous procainamide, amiodarone, or sotalol may be reasonable to consider.

After cardiac arrest in infants and children, it is recommended to maintain systolic and mean arterial blood pressure greater than the 10th percentile for age. Hypotension is common after ROSC (in 25% to 50% of children) and is associated with lower rates of survival to discharge.

For the first time, formal guidance on predicting neurological outcome after pediatric cardiac arrest is included.

• Clinicians should consider multiple modalities; no single test should be used in isolation.
• The usefulness of cough or gag reflexes or response to pain to support a favorable or unfavorable prognosis at any time point is not well established.
• When interpreted with other prognostic criteria, EEG up to 72 hours after cardiac arrest is reasonable to support a favorable or unfavorable neurological prognosis.

It is reasonable that infants and children who survive cardiac arrest be evaluated for physical, cognitive, and emotional needs to guide follow-up care within the first year. Recovery continues long after initial hospitalization, and survivors may require integrated medical, rehabilitative, caregiver, and community support.

For an adult with head and neck trauma, if the airway cannot be opened with a jaw thrust and airway adjunct, trained rescuers should open the airway using a head-tilt–chin-lift. A patent airway for oxygenation and ventilation is the priority, even when cervical-spine precautions are otherwise preferred.

When providing ventilation for an adult in respiratory arrest, give one ventilation every 6 seconds (10 breaths per minute), with each ventilation creating visible chest rise.

When ventilating an adult in cardiac arrest, deliver enough tidal volume to produce visible chest rise. Rescuers should avoid both hypoventilation (too few breaths or too little volume) and hyperventilation (too many breaths or too large a volume). CPR with effective ventilation and chest compressions has been associated with improved outcomes.

It is reasonable for lay rescuers and clinicians to perform CPR with cycles of 30 compressions followed by 2 breaths before placement of an advanced airway. The pause for breaths allows the rescuer to monitor chest rise and verify ventilation is adequate.

When placing pads for defibrillation, it might be reasonable to adjust the position of a bra instead of removing it. Women experience significantly lower rates of public-access defibrillation than men; the requirement to fully expose the chest is a contributing factor. The option to adjust rather than remove can mitigate rescuer hesitation and improve response.

The routine use of mechanical CPR devices is not recommended for adult cardiac arrest. Their use may be considered in specific settings where delivery of high-quality manual compressions would be challenging or dangerous — provided interruptions during deployment and removal are strictly limited.

CPR for adults with obesity who are in cardiac arrest should be provided using the same techniques as for patients without obesity. A 2024 ILCOR scoping review of 34 observational studies found no evidence to support changes from standard CPR. Compressions should be performed with the patient on a firm surface, with the torso at approximately the level of the rescuer's knees.

For adults with severe foreign-body airway obstruction, perform repeated cycles of 5 back blows (slaps) followed by 5 abdominal thrusts until the object is expelled or the person becomes unresponsive.

For patients in late pregnancy or when the rescuer cannot encircle the abdomen, 5 chest thrusts should be used in place of abdominal thrusts.

The Health Care Professional BLS Algorithm has been updated to illustrate the role of an opioid antagonist (e.g., naloxone) for suspected opioid overdose during respiratory and cardiac arrest.

The usefulness of vector-change defibrillation for adults in cardiac arrest with persisting ventricular fibrillation or pulseless ventricular tachycardia after 3 or more consecutive shocks has not been established. Evidence supporting the technique is currently limited to a single small RCT, with a number of outstanding questions requiring further investigation.

Similarly, the usefulness of double sequential defibrillation in adults in cardiac arrest with persisting VF or pulseless VT after 3 or more consecutive shocks has not been established. The same single small RCT informs both this and the vector-change recommendation.

It is recommended that clinicians first attempt to establish IV access for drug administration in adult cardiac arrest.

Intraosseous access is reasonable if initial IV attempts are unsuccessful or not feasible. A 2025 ILCOR systematic review and meta-analysis (including data from 3 recent large RCTs) noted lower odds of sustained ROSC for the IO route compared with the IV route.

In consideration of timing, for adult patients in cardiac arrest with a shockable rhythm, it is reasonable to administer epinephrine after initial defibrillation attempts have failed. The literature supports prioritizing rapid defibrillation first.

Vasopressin alone, or vasopressin combined with epinephrine, offers no advantage as a substitute for epinephrine for adult patients in cardiac arrest. Multiple systematic reviews and meta-analyses have shown no difference in survival outcomes.

For adults in cardiac arrest, the use of β-blockers, bretylium, procainamide, or sotalol for VF or pulseless VT unresponsive to defibrillation is of uncertain benefit. No new evidence emerged from a 2025 ILCOR update on these parenteral antiarrhythmic agents.

Head-up CPR in adults with cardiac arrest is not recommended except in the setting of clinical trials. A recent ILCOR systematic review identified no RCTs and only 3 observational studies, each with significant methodological limitations.

In a tiered EMS system with both ALS and BLS clinicians, it is reasonable to use the universal termination-of-resuscitation rule for adult OHCA. The criteria — arrest not witnessed by EMS, no shock delivered, and no ROSC — have been prospectively validated in combined BLS/ALS agencies.

Synchronized cardioversion is recommended for acute treatment of adult patients with hemodynamically unstable wide-complex tachycardia.

For hemodynamically stable wide-complex tachycardia, synchronized cardioversion is recommended when vagal maneuvers and pharmacologic therapy are ineffective or contraindicated.

For synchronized cardioversion of atrial fibrillation using any currently U.S.-approved biphasic defibrillator, an initial energy setting of at least 200 J is reasonable, with increments if a shock fails.

For synchronized cardioversion of atrial flutter, an initial setting of 200 J may be reasonable, with increments as needed.

The usefulness of double synchronized cardioversion of AF as an initial strategy is uncertain.

In adults with persistent, hemodynamically unstable bradycardia refractory to medical therapy, temporary transvenous pacing is reasonable to increase heart rate and improve symptoms until more definitive treatment (correction of underlying cause or permanent pacemaker placement) can be implemented.

Hypotension should be avoided in adults after ROSC by maintaining a minimum mean arterial pressure of at least 65 mm Hg. Four randomized trials comparing lower to higher MAP targets did not demonstrate better overall survival or favorable neurologic outcome with higher MAP. There is insufficient evidence to recommend a specific vasopressor.

It may be reasonable to perform head-to-pelvis computed tomography for adult patients after ROSC to investigate the etiology of cardiac arrest and complications from resuscitation.

It may be reasonable to perform echocardiography or point-of-care cardiac ultrasound for adult patients after ROSC to identify clinically significant diagnoses requiring intervention.

Temperature control should be maintained for at least 36 hours in adults who remain unresponsive to verbal commands after ROSC. Temperature control includes:

• Hypothermic targets (32–34 °C)
• Normothermic / fever-prevention targets (36–37.5 °C)

36 hours is the shortest recommended total duration.

Coronary angiography is recommended before hospital discharge in adult cardiac arrest survivors with suspected cardiac etiology — particularly with an initial shockable rhythm, unexplained left ventricular systolic dysfunction, or evidence of severe myocardial ischemia. Identifying and treating unstable coronary disease has been shown to improve outcomes.

In highly selected adult patients with refractory cardiogenic shock after cardiac arrest and ROSC, temporary mechanical circulatory support may be considered. Cardiogenic shock occurs commonly as either a cause or consequence of arrest, and temporary mechanical circulatory devices can provide hemodynamic stabilization.

Treatment to suppress myoclonus without an EEG correlate is not recommended in adult survivors of cardiac arrest. There is no evidence implicating such myoclonus in secondary brain injury, and the risk of side effects outweighs the unknown benefit.

The neuroprognostication section was updated to include predictors of favorable outcome, and neurofilament light chain has been added as a serum biomarker.

When evaluated alongside other prognostic tests, a continuous EEG background without discharges within 72 hours after cardiac arrest may be reasonable to support a prognosis of favorable neurological outcome in comatose adults after ROSC. Multimodal assessment remains essential — no single test should predict outcome in isolation.

Cardiac arrest survivors and their caregivers should have structured assessment and treatment of (or referral for) emotional distress after medical stabilization and before hospital discharge. Approximately one-fourth of survivors and caregivers experience emotional distress, and psychosocial interventions have shown measurable improvement.

Preparation for resuscitative delivery — the new term replacing "perimortem cesarean delivery" — should begin at the recognition of cardiac arrest in a pregnant patient, with the goal of completing delivery by 5 minutes. Manual left lateral uterine displacement and standard resuscitation continue concurrently.

It is reasonable to use ECPR in pregnant or peripartum patients in cardiac arrest not responsive to standard resuscitation. Studies report survival rates of approximately 55%–75% for pregnant patients managed with ECPR.

A massive transfusion protocol with a balanced transfusion strategy (red blood cells, plasma, and platelets in equivalent proportions) should be used for peripartum patients with suspected life-threatening amniotic fluid embolism. The condition can cause hemodynamic compromise, respiratory distress, and disseminated intravascular coagulation with resultant hemorrhage.

An opioid antagonist (e.g., naloxone) should be given to people in respiratory arrest from suspected opioid overdose. Lay rescuers, trained rescuers, and members of the general public can all administer naloxone.

In cardiac arrest with suspected opioid overdose, naloxone administration may be reasonable provided it does not interfere with high-quality CPR (including breaths).

Adults and children who are treated for opioid overdose should receive an opioid antagonist and instruction on how to use it at the time of discharge from a health-care setting. People who survive an overdose are at high risk of a subsequent overdose.

In unresponsive adults and children with a durable LVAD and impaired perfusion, chest compressions should be performed. It may be reasonable to start chest compressions immediately while simultaneously assessing for device-related reversible causes (alarm checks, LVAD hum, driveline and power connections, controller status). The potential benefit of CPR outweighs the theoretical risk of device dislodgment.

It may be reasonable to use extracorporeal life support for adults and children with life-threatening asthma refractory to standard therapies. Treatment with volatile anesthetics may also be considered. Adult and pediatric observational studies of ECLS or volatile anesthetics report survival rates between approximately 83.5% and 100%.

For adults and children in cardiac arrest from suspected hyperkalemia, the effectiveness of IV calcium administration is not well established. The decision must be carefully weighed against the potential for detracting from time-sensitive resuscitative interventions including high-quality CPR, defibrillation of shockable rhythms, and administration of epinephrine.

It is reasonable to use validated prognostication scores — the HOPE probability score and the ICE survival score — to guide the decision for initiating ECLS rewarming in hypothermic cardiac arrest.

For adults and children with severe environmental hypothermia (core temperature <28 °C) not in cardiac arrest, ECLS rewarming may also be reasonable — with the understanding that ECLS can rewarm more quickly but carries its own risks.

It is reasonable to choose immersion in ice water (1–5 °C) over other cooling methods for adults and children with life-threatening hyperthermia, and to cool as rapidly as possible — with a decrease of at least 0.15 °C per minute. These recommendations also apply to hyperthermia associated with sympathomimetic and cocaine poisoning.

Chest compressions, bag-mask ventilation, defibrillation, suctioning, and endotracheal intubation should all be considered aerosol-generating procedures that pose an infection risk to resuscitation team members.

Feedback devices are recommended for use during CPR training for both health-care professionals and lay rescuers. A meta-analysis with clinicians demonstrated a moderate to large effect on CPR quality metrics; RCTs with lay rescuers showed similar improvements.

It may be reasonable to incorporate rapid-cycle deliberate practice as part of BLS or ALS training for clinicians. This simulation-based method incorporates within-event debriefing and has been shown to improve performance of multiple CPR skills and workload scores.

It is recommended that life-support training for clinicians include a specific emphasis on teamwork competencies. Twelve of 14 RCTs reviewed reported superior performance after specific teamwork training across communication, leadership behavior, non-technical skills, workload management, and overall teamwork.

It may be reasonable to use gamified learning elements as a component of resuscitation training for both clinicians and lay rescuers. Gamified learning is associated with improved CPR knowledge, skill performance, and self-confidence, although the supporting evidence is currently weak.

It may be reasonable to use virtual reality to support knowledge acquisition in BLS and ALS training for both clinicians and lay rescuers.

However, virtual reality should not be used to teach CPR skills — studies of skill outcomes such as compression depth and rate show VR-based training is either inferior to or no different from other methods.

The use of augmented reality to provide real-time CPR feedback may be considered for BLS training of lay rescuers and clinicians.

It is recommended that lay rescuers receive education on recognition and initial treatment steps for opioid-associated OHCA. The optimal training method has not yet been established, but training has been shown to increase knowledge, improve willingness to respond, and increase the likelihood of action.