2025 ACLS Guideline Changes: What's Different From 2020

ACLS Cards · Updated November 3, 2026 · Adult · 2025 guidelines · Clinical review pending

The 2025 Guidelines for CPR and Emergency Cardiovascular Care were published in October 2025 and replace the 2020 guidelines and their focused updates. Here's what changed for adult advanced life support, in plain language. Each item is checked against the published guideline text for our cheat sheet pack and is pending final clinician review.

Cardiac arrest

• IV first, then IO. IV access is preferred first; IO is reasonable if IV is unsuccessful^{pending review, ref G3}.
• Epinephrine timing by rhythm. Nonshockable rhythms: as soon as possible. Shockable rhythms: after initial defibrillation attempts have failed^{pending review, ref G4}.
• Endotracheal drug route removed. Drugs are no longer given down the endotracheal tube^{pending review, ref G7}.
• Vector change / double sequential defibrillation. For refractory VF after 3 or more shocks, usefulness is not established^{pending review, ref G5}.
• Head-up CPR. Not recommended outside research trials^{pending review, ref G6}.
• Point-of-care ultrasound. May be considered by experienced users, without interrupting CPR^{pending review, ref G8}.
• Termination of resuscitation. EMS rules are matched to the team's scope (BLS, ALS or universal); ETCO₂ is never used alone, and there's no ETCO₂ cutoff in non-intubated patients^{pending review, ref G9}.
• Other antiarrhythmics. β-blockers, bretylium, procainamide and sotalol during arrest have uncertain benefit^{pending review, ref G12}.

Tachycardia

• Higher starting energy for AF and flutter. AF ≥200 J and flutter 200 J, instead of escalating from a low energy^{pending review, ref G1}.
• Polymorphic VT. Sustained polymorphic VT: immediate unsynchronized shock^{pending review, ref G2}.
• Terminology and drugs. "SVT" becomes narrow-complex tachycardia; sotalol is removed from the algorithm; more emphasis on whether the rhythm is the cause or a consequence^{pending review, ref G10}.

Bradycardia

• Transvenous pacing. Temporary transvenous pacing is reasonable when medical therapy fails^{pending review, ref G11}.

Post-cardiac arrest care

• MAP 65 mm Hg or higher; SpO₂ 90–98%; temperature control at 32–37.5 °C for at least 36 h; no rapid prehospital cold IV fluid; head-to-pelvis CT and echo; neurofilament light (NfL) added to prognostication; prognosis at 72 h or later^{pending review, ref G13}.

Systems of care

• A single chain of survival; hot and cold debriefs; cognitive aids^{pending review, ref G14}.

BLS changes that ACLS providers should know

• No fixed ventilation volume (give enough for visible chest rise); torso at about the rescuer's knee level; no routine mechanical CPR; adult choking: 5 back blows then 5 abdominal thrusts^{pending review, ref G15}.
• Naloxone is included in the BLS algorithm for suspected opioid emergencies^{pending review, ref G16}.

ACS and stroke (course content)

• New LBBB is no longer automatically treated as a STEMI equivalent; fentanyl added alongside morphine; clopidogrel no longer the default; enoxaparin, fondaparinux and ACE inhibitors added^{pending review, ref G17}.
• Tenecteplase added for stroke^{pending review, ref G18}.

Source: 2025 Guidelines for CPR and Emergency Cardiovascular Care (Circulation, October 2025), as summarized in the pack's source checklist. Original wording and layout; no guideline figures reproduced.