Adult Cardiopulmonary Resuscitation (CPR) – 2025 American Heart Association Recommendations
Initial Assessment and Activation
- Check responsiveness by loudly calling the patient’s name and tapping the shoulders. American Heart Association recommends this as the first step in adult cardiac arrest assessment. 1
- Within 10 seconds simultaneously assess breathing and pulse, looking for absent or agonal respirations and confirming the presence of a definite pulse. American Heart Association emphasizes this rapid dual assessment. 2
- Immediately shout for nearby help and activate the emergency response system (e.g., via a mobile device) as soon as cardiac arrest is suspected. American Heart Association guidance. 1
- Send a rescuer to retrieve an automated external defibrillator (AED) and other emergency equipment without delay. American Heart Association protocol. 2
High‑Quality Chest Compression Technique
- Perform chest compressions at a depth of at least 2 inches (5 cm) and a rate of 100–120 compressions per minute; compressions should be hard and fast. American Heart Association class I recommendation. 1
- Ensure full chest recoil between compressions to maximize cardiac filling. American Heart Association recommendation. 2
- Keep interruptions to <10 seconds; pauses longer than this markedly reduce coronary perfusion. American Heart Association emphasizes minimal interruptions. 1
- Rotate compressors every 2 minutes (or sooner if fatigued) to maintain compression quality. American Heart Association guideline. 2
Compression‑to‑Ventilation Ratio
- Deliver cycles of 30 compressions followed by 2 breaths for all adult cardiac arrests (C‑A‑B sequence). American Heart Association standard ratio. 1
- Avoid excessive ventilation because it raises intrathoracic pressure and reduces cardiac output. American Heart Association warning. 1
Defibrillation Protocol (AED Use)
- Apply the AED as soon as it is available; do not pause compressions while preparing the device. American Heart Association instruction. 2
- When the AED prompts, deliver a single shock for shockable rhythms (ventricular fibrillation or pulseless ventricular tachycardia). American Heart Association directive. 1
- Immediately resume CPR with chest compressions after shock delivery; do not check pulse or rhythm before compressions. American Heart Association recommendation. 2
- Continue CPR for a full 2 minutes before the AED prompts the next rhythm analysis. American Heart Association timing guidance. 1
- Use biphasic defibrillators with an initial energy of 120–200 J (follow manufacturer’s recommendation; if unknown, use the maximum available setting). American Heart Association energy guideline. 2
- Subsequent shocks should be of equal or higher energy than the preceding dose. American Heart Association protocol. 2
Rhythm and Pulse Check Timing
- Perform rhythm analysis every 2 minutes during CPR cycles; keep each pause <10 seconds to avoid compromising perfusion. American Heart Association timing recommendation. 2
Medication Administration
- Give epinephrine 1 mg intravenously or intra‑osseously every 3–5 minutes for all cardiac arrest rhythms. American Heart Association class I, Level A recommendation. 1
- For refractory ventricular fibrillation/pulseless ventricular tachycardia, administer amiodarone (first dose 300 mg, second dose 150 mg) or lidocaine (first dose 1–1.5 mg/kg, second dose 0.5–0.75 mg/kg). American Heart Association guideline. 2
Advanced Airway Management
- After securing an advanced airway (endotracheal tube or supraglottic device), provide one breath every 6 seconds (≈10 breaths/min) while maintaining continuous chest compressions—no pauses for ventilation. American Heart Association recommendation. 2
Extracorporeal CPR (ECPR)
- ECPR is reasonable for selected patients with refractory cardiac arrest when performed within a system that has appropriate training and equipment. American Heart Association 2025 update. 3
- The ARREST trial showed significantly higher survival for patients with shockable rhythms who received ECPR after prolonged resuscitation attempts. American Heart Association evidence. 3
Medication Recommendations – What Not to Use
- Atropine is no longer recommended for routine use in pulseless electrical activity or asystole. American Heart Association 2025 guideline change. 3
- Routine sodium bicarbonate administration is discouraged because it may worsen survival and neurological outcomes. American Heart Association recommendation. 3
Post‑Return of Spontaneous Circulation (ROSC) Care – Coronary Intervention
- Perform emergent coronary angiography for any cardiac arrest patient presenting with ST‑segment elevation on ECG. American Heart Association class I recommendation. 3
- Consider emergent angiography for selected patients without ST‑elevation but who have high coronary risk, cardiogenic shock, or electrical instability. American Heart Association class IIa recommendation. 3
Common Pitfalls to Avoid
- Do not check the pulse immediately after shock delivery; this wastes critical time that should be spent resuming compressions. American Heart Association warning. 2
- Avoid hyperventilation; excessive ventilation reduces cardiac output and cerebral blood flow. American Heart Association caution. 1
Rhythm and Pulse Checks During CPR
Timing and Frequency
- The American Heart Association recommends performing rhythm and pulse checks every 2 minutes during CPR, immediately after completing each cycle of chest compressions 4, 5, 6, 7, 8
- Check rhythm every 2 minutes following continuous CPR cycles, whether you are using an automated external defibrillator (AED) or manual defibrillator 4, 5, 6
- Resume CPR immediately after shock delivery without performing a rhythm or pulse check, and continue compressions for the full 2-minute cycle before the next rhythm assessment 4, 5, 6, 7
- Pulse checks should only be performed if an organized rhythm is observed during the 2-minute rhythm check—if there is any doubt about pulse presence, resume chest compressions immediately 4, 6
Workflow During CPR
- With an AED, deliver one shock when prompted, immediately resume CPR starting with chest compressions, and continue CPR for 2 minutes until the AED prompts the next rhythm check 4, 5, 6, 8
- With a manual defibrillator, first provider resumes CPR while second provider charges the defibrillator, pause briefly to "clear" and deliver shock, and first provider immediately resumes CPR starting with chest compressions 4, 5, 6, 8
Key Recommendations
- Do not check pulse or rhythm immediately after shock delivery—this wastes critical time when chest compressions should be ongoing 4, 5, 6
- Do not interrupt compressions for frequent rhythm checks—each interruption decreases coronary and cerebral perfusion pressure, reducing the likelihood of successful resuscitation 4, 7
- Keep rhythm checks brief (less than 10 seconds)—prolonged pauses for assessment significantly worsen outcomes 4, 6, 8
- Change compressors every 2 minutes at the time of rhythm checks to prevent fatigue and maintain compression quality 4, 5, 6, 7
Additional Monitoring Considerations
- Continuous monitoring of CPR quality should occur throughout using mechanical parameters (compression depth, rate) or physiologic parameters (end-tidal CO2, arterial pressure if available) 4, 5, 6
- If waveform capnography shows a sudden sustained increase in end-tidal CO2, this may indicate ROSC and warrants an immediate rhythm and pulse check even before the 2-minute interval 8
Cardiac Arrest Management
Initial Resuscitation Steps
- The American Heart Association recommends starting CPR immediately with cycles of 30 compressions and 2 breaths, ensuring high-quality compressions of at least 2 inches (5 cm) depth at a rate of 100-120 per minute 9, 10
- Use of an automated external defibrillator (AED) is recommended as soon as it becomes available, with delivery of one shock and immediate resumption of CPR for 2 minutes before reassessing rhythm 9, 11
Advanced Life Support
- The American Heart Association suggests establishing IV/IO access for medication administration and administering epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms 10, 11
- For refractory ventricular fibrillation/pulseless ventricular tachycardia, administration of amiodarone or lidocaine is recommended 10, 11
Airway Management
- Placement of an endotracheal tube or supraglottic airway device is recommended, with confirmation of tube placement using waveform capnography or capnometry 11, 12
- Once advanced airway is placed, provision of 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions is suggested 11, 12
Post-ROSC Care
- The American Heart Association recommends immediate initiation of post-cardiac arrest care after achieving ROSC, including targeting a mean arterial pressure of at least 65 mmHg and oxygen saturation of 92-98% 12, 13, 14
Quality Improvement
- Minimizing interruptions in chest compressions and changing compressors every 2 minutes or sooner if fatigued is recommended to improve CPR quality 10, 11
Guidelines for Achieving Return of Spontaneous Circulation in Adult Cardiac Arrest
Initial Response and Early CPR
- The emergency response system should be activated and chest compressions started within 10 seconds of recognizing cardiac arrest, with a loud call for help to summon additional rescuers. (American Heart Association) 15
- Chest compressions should begin immediately, without removing the patient’s clothing, to avoid any delay. (American Heart Association) 15
High‑Quality Chest Compression Technique
- Perform compressions at a depth of ≥ 2 inches (5 cm) and a rate of 100–120 compressions per minute. (American Heart Association) 15, 16
- Ensure complete chest recoil between compressions; rescuers must not lean on the patient’s thorax. (American Heart Association) 15
- Keep interruptions < 10 seconds; longer pauses markedly reduce coronary perfusion pressure. (American Heart Association) 15
- Rotate compressors every 2 minutes (or sooner if fatigued) to maintain optimal compression quality. (American Heart Association) 15, 16
- Use a 30:2 compression‑to‑ventilation ratio (30 compressions followed by 2 breaths) for adult patients without an advanced airway. (American Heart Association) 15, 16
- Avoid excessive ventilation because it raises intrathoracic pressure and diminishes cardiac output. (American Heart Association) 15, 17
Defibrillation Protocol
- Apply an automated external defibrillator (AED) as soon as it is available; do not pause compressions while preparing the device. (American Heart Association) — citation embedded in overall protocol 15
- Deliver a single shock when prompted by the AED/defibrillator. (American Heart Association) 15
- Use biphasic energy of 120–200 J for the initial shock; if the recommended energy is unknown, use the maximum available output. (American Heart Association) 15, 16, 17
- Subsequent shocks should be equal to or higher than the previous energy level. (American Heart Association) 15
- Immediately resume chest compressions after shock delivery; do not check pulse or rhythm before compressions. (American Heart Association) 15
- Continue CPR for a full 2‑minute interval before the next rhythm analysis. (American Heart Association) 15
Medication Administration
- Epinephrine 1 mg IV/IO should be given every 3–5 minutes for all cardiac‑arrest rhythms. (American Heart Association) 15, 16, 17
- Obtain IV or IO vascular access as early as possible during the resuscitation effort. (American Heart Association) 15
- For refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT):
Advanced Airway Management
- When an advanced airway is placed, use either endotracheal intubation or a supraglottic airway device. (American Heart Association) 15, 17
- Confirm airway placement immediately with waveform capnography or capnometry. (American Heart Association) 15, 17
- Deliver 1 breath every 6 seconds (≈10 breaths/min) while maintaining continuous chest compressions; no pauses for ventilation are permitted. (American Heart Association) 15, 16, 17
Rhythm Checks and ROSC Detection
- Perform rhythm analysis every 2 minutes, ensuring each pause is < 10 seconds. (American Heart Association) 15
- Signs of Return of Spontaneous Circulation (ROSC) include:
Identification and Treatment of Reversible Causes (H’s and T’s)
- Systematically evaluate for the following reversible etiologies throughout resuscitation:
- Hypovolemia, Hypoxia, Acidosis (hydrogen ion excess)
- Hypo‑/hyperkalemia, Hypothermia
- Tension pneumothorax, Cardiac tamponade
- Toxins, Pulmonary thrombosis, Coronary thrombosis
Post‑ROSC Hemodynamic and Respiratory Targets
- After ROSC, target an oxygen saturation of 92–98 % to avoid both hypoxemia and hyperoxemia. (American Heart Association) 18
- Administer 100 % inspired oxygen initially until reliable arterial oxygen measurement is obtained. (American Heart Association) 18
Confirmation of True Return of Spontaneous Circulation (ROSC)
Definition of True ROSC
- True ROSC is defined as restoration of a spontaneous perfusing rhythm that lasts ≥ 30 seconds and is evidenced by more than occasional gasping, a sustained palpable pulse, measurable arterial blood pressure, or a visible arterial waveform on invasive monitoring. 19
Clinical Indicators of Sustained ROSC
- Breathing – presence of regular respirations beyond occasional gasps indicates true ROSC. 19
- Coughing – spontaneous coughing is a reliable sign of adequate perfusion. 19
- Purposeful movement – any purposeful motor activity confirms sustained circulation. 19
- Palpable carotid pulse that persists for > 30 seconds confirms true ROSC and should be timed during rhythm checks. 19
- Measurable arterial blood pressure (target mean arterial pressure ≥ 65 mm Hg) supports the presence of effective perfusion. 19
Distinguishing Transient Epinephrine‑Induced Pulse from True ROSC
- An epinephrine‑induced pulse typically appears 1–2 minutes after epinephrine administration (epinephrine is given every 3–5 minutes) and lasts only seconds to < 30 seconds before disappearing. [20][19]
- This transient pulse does not produce spontaneous breathing, coughing, purposeful movement, or measurable blood pressure. 19
Confirmation Algorithm (Key Steps)
- During the 2‑minute rhythm check, after organized rhythm is identified, assess for breathing, coughing, or purposeful movement. 19
- If a carotid pulse is felt, verify that it persists for > 30 seconds before declaring ROSC. 19
- Confirm measurable arterial blood pressure immediately after pulse detection. 19
- If the pulse disappears within seconds, treat it as a transient epinephrine effect and resume CPR without delay. 19
- When all criteria (sustained pulse > 30 seconds, clinical signs of perfusion, measurable blood pressure) are met, transition to post‑ROSC care. 19
Post‑ROSC Monitoring and Stability
- Rearrest occurs in approximately 36 % of patients after initial ROSC, with a median time to rearrest of ≈ 3.1 minutes. Sustained ROSC is defined as lasting until hospital admission for out‑of‑hospital arrests or ≥ 20 minutes for in‑hospital arrests. 21
- Continuous monitoring for at least 20 minutes is recommended to differentiate sustained ROSC from transient ROSC. 21
All facts are derived from peer‑reviewed consensus and clinical studies published in Circulation and are presented with the associated citation identifiers.