American Heart Association Guidelines for Cardiac Arrest Management

Universal Foundations – High‑Quality CPR

• The American Heart Association (AHA) states that immediate recognition of cardiac arrest and initiation of high‑quality CPR are the essential first steps for all patients, regardless of rhythm. [1] [2]
• The AHA recommends chest compressions at a depth of at least 5 cm (≈2 in) and a rate of 100–120 compressions per minute. [2] [3]
• The AHA advises allowing complete chest recoil after each compression to maximize coronary perfusion. [1] [2]
• The AHA emphasizes minimizing interruptions; pauses for rhythm checks, defibrillation, or pulse assessment should be kept under 10 seconds. 1
• The AHA recommends a ventilation ratio of 30 compressions : 2 breaths when no advanced airway is in place, then 1 breath every 6 seconds (≈10 breaths/min) with continuous compressions after airway placement. [1] [2]
• The AHA advises rotating the person performing compressions every 2 minutes, or sooner if fatigue develops. [2] [3]

Shockable Rhythm (VF / Pulseless VT) Management

• The AHA directs immediate defibrillation with minimal interruption of compressions; biphasic shocks of 120–200 J (manufacturer‑specified) or monophasic 360 J are used. [2] [3]
• After each shock, the AHA instructs resuming CPR for a full 2‑minute cycle before the next rhythm check. 2
• The AHA recommends establishing IV/IO access and administering epinephrine 1 mg IV/IO every 3–5 minutes during resuscitation. [2] [3]
• For refractory VF/pVT after 2–3 shocks, the AHA suggests either amiodarone (300 mg bolus, then 150 mg) or lidocaine (1–1.5 mg/kg, then 0.5–0.75 mg/kg). The 2018 update notes that both drugs are considered equivalent and neither improves long‑term survival. [3] [4]
• The AHA advises continuing 2‑minute CPR cycles with rhythm checks until return of spontaneous circulation (ROSC) or a decision to terminate resuscitation. 2

Non‑Shockable Rhythm (PEA / Asystole) Management

• The AHA mandates immediate high‑quality CPR without delay for rhythm analysis. 2
• The AHA recommends giving epinephrine 1 mg IV/IO as soon as possible, then every 3–5 minutes. 2
• The AHA stresses the importance of searching for reversible causes (the “H’s and T’s”) while CPR continues.
  
  • H’s: hypovolemia, hypoxia, acidosis, electrolyte disturbances, hypothermia.
  • T’s: tension pneumothorax, cardiac tamponade, toxins, pulmonary or coronary thrombosis. [2] [5]
• The AHA specifies rhythm checks every 2 minutes during CPR cycles. 2
• If the rhythm converts to VF/pVT, the AHA advises switching to the shockable‑rhythm algorithm. 2

Airway Management During Cardiac Arrest

• The AHA recommends beginning ventilation with a bag‑mask using a 30:2 compression‑ventilation ratio. 2
• The AHA cautions that placement of an advanced airway (endotracheal tube or supraglottic device) must not cause prolonged interruptions of chest compressions. 1
• The AHA requires immediate confirmation of airway placement with waveform capnography. [2] [3]
• The AHA notes that an end‑tidal CO₂ (PETCO₂) value < 10 mmHg signals inadequate CPR quality and should prompt corrective actions. [2] [3]
• After an advanced airway is secured, the AHA directs continuous compressions with 1 breath every 6 seconds. [1] [2]

Monitoring CPR Quality

• The AHA advises using quantitative waveform capnography, targeting PETCO₂ > 10 mmHg (ideally 10–20 mmHg) during resuscitation. [2] [3]
• When intra‑arterial pressure monitoring is available, the AHA recommends a diastolic (relaxation‑phase) pressure > 20 mmHg. [1] [3]
• The AHA indicates that a sudden sustained rise in PETCO₂ to ≥ 40 mmHg is a strong indicator of ROSC. [2] [3]

Recognizing Return of Spontaneous Circulation (ROSC)

• The AHA defines ROSC by the return of palpable pulse and measurable arterial pressure, an abrupt PETCO₂ increase > 40 mmHg, and spontaneous arterial pressure waveforms on invasive monitoring. [2] [3]

Post‑ROSC Care

• The AHA recommends not giving routine prophylactic antiarrhythmic drugs after ROSC, as no survival benefit has been demonstrated. [3] [4]
• The AHA allows consideration of prophylactic lidocaine during EMS transport when recurrent VF/pVT would be logistically difficult to treat. 4

Common Pitfalls to Avoid (AHA‑Based)

• The AHA warns against interrupting compressions for prolonged advanced‑airway placement; only brief pauses are permissible. 1
• The AHA cautions against excessive ventilation, especially after airway placement, because it raises intrathoracic pressure and reduces venous return. 1
• The AHA stresses that treatment decisions must consider the whole clinical context, not rhythm alone. [5] [6]

Tachycardia With Pulse (Periarrest) Algorithm

• The AHA advises first assessing patient stability (altered mental status, chest pain, acute heart failure, hypotension, or shock). [5] [6]
• If the patient is unstable, the AHA recommends immediate synchronized cardioversion. [5] [6]
• If stable and the rhythm is narrow‑complex regular, the AHA suggests a rapid IV push of adenosine 6 mg, followed by 12 mg if needed. [5] [6]
• If stable and the rhythm is wide‑complex, the AHA treats it as ventricular tachycardia until proven otherwise, using antiarrhythmics such as amiodarone, procainamide, or lidocaine. [5] [6]
• The AHA notes that heart rates < 150 bpm rarely cause instability unless there is underlying ventricular dysfunction; clinicians should search for precipitating causes. 5

Adult Cardiac Arrest Management

Immediate Recognition and Activation

• The American Heart Association recommends simultaneous activation of the emergency response system and initiation of CPR immediately upon recognizing cardiac arrest, with an emphasis on minimizing interruptions in chest compressions 7, 8
• Assessment for pulse and responsiveness should be done within 10 seconds, and if no definite pulse is felt, CPR should be started immediately 9

High-Quality CPR Foundation

• The American Heart Association emphasizes that all ACLS interventions are built upon the foundation of high-quality CPR, which is critical to survival 9, 7
• High-quality CPR involves pushing hard (at least 2 inches/5 cm depth) and fast (at least 100-120 compressions per minute), allowing complete chest recoil after each compression, and minimizing interruptions in compressions to less than 10 seconds 9, 10

Rhythm Identification and Management

• For shockable rhythms, the American Heart Association recommends defibrillation with minimal interruption in compressions, using biphasic 120-200J or monophasic 360J, and resuming CPR immediately after shock delivery for 2 minutes before checking rhythm 7, 8, 9
• For non-shockable rhythms, epinephrine 1 mg IV/IO should be administered as soon as possible and repeated every 3-5 minutes, with continued high-quality CPR and rhythm checks every 2 minutes 7, 8, 9

Airway Management

• Initial ventilation should be provided with a bag-mask device (30:2 ratio with compressions), and advanced airway placement should be considered when appropriate, without interrupting compressions for prolonged periods 9, 10

Vascular Access and Medications

• Epinephrine 1 mg IV/IO every 3-5 minutes improves survival, particularly in non-shockable rhythms, according to the American Heart Association 7, 8

Post-ROSC Care

• The American Heart Association recommends maintaining mean arterial pressure ≥65 mmHg with vasopressors, targeting SpO2 92-98% to avoid both hypoxia and hyperoxemia, and initiating targeted temperature management for all patients who do not follow commands after ROSC 7, 8, 11

2025 American Heart Association Advanced Cardiac Life‑Support Guideline Highlights

Core CPR Quality Standards

• The American Heart Association recommends chest compressions of at least 5 cm depth at a rate of 100–120 compressions per minute for all cardiac arrests. 12
• Compressor rotation should occur every 2 minutes or sooner if fatigue develops to maintain compression quality. 13
• When no advanced airway is in place, use a 30:2 compression‑to‑ventilation ratio. 12
• After placement of an advanced airway, provide continuous compressions with one breath every 6 seconds (≈10 breaths/min). 13

Shockable Rhythm (VF/pulseless VT) Management

• For refractory VF/pVT after 2–3 shocks, either amiodarone or lidocaine may be administered; both are considered equivalent and have not demonstrated improvement in long‑term survival or neurological outcome. 12
• Recommended dosing (when used):
  
  • Amiodarone – 300 mg IV/IO bolus, then 150 mg infusion. 13
  • Lidocaine – 1–1.5 mg/kg IV/IO loading dose, then 0.5–0.75 mg/kg repeat doses. 12
• Evidence shows these antiarrhythmics improve short‑term ROSC and hospital admission, but do not improve survival to discharge or favorable neurologic outcome. 13

Advanced Airway Management

• An advanced airway (endotracheal tube or supraglottic device) should be attempted only when it can be placed without prolonged interruption of chest compressions. 14
• Waveform capnography must be used to confirm airway placement; this confirmation is mandatory. 15
• Following successful airway placement, continue continuous compressions with one breath every 6 seconds. 12

CPR Quality Monitoring

• Use quantitative waveform capnography targeting a PETCO₂ > 10 mmHg (ideally 10–20 mmHg) during resuscitation. 13
• A PETCO₂ < 10 mmHg indicates inadequate CPR quality and should trigger immediate corrective actions. 12
• When available, intra‑arterial diastolic pressure > 20 mmHg is recommended as an additional quality metric. 13
• ETCO₂ values alone must not be used to predict mortality or to decide termination of resuscitation. 15

Recognition of Return of Spontaneous Circulation (ROSC)

• ROSC is confirmed by palpable pulse and measurable arterial blood pressure. 12
• An abrupt sustained rise in PETCO₂ to ≥ 40 mmHg is a reliable physiologic indicator of ROSC. 13
• Presence of spontaneous arterial pressure waveforms on invasive monitoring also confirms ROSC. 12

Post‑ROSC Care

Oxygenation & Ventilation

• Avoid both hypoxia and hyperoxia; initially use 100 % oxygen until reliable arterial oxygenation can be measured, then titrate to SpO₂ 92–98 %. 16
• Maintain PaCO₂ within the normal physiological range. 15

Hemodynamic Targets

• Aim for a mean arterial pressure (MAP) ≥ 65 mmHg in the post‑arrest period. 16

Targeted Temperature Management (TTM)

• When temperature control is employed, maintain a constant target temperature between 32 °C and 36 °C. 15
• TTM is recommended for adults with out‑of‑hospital cardiac arrest who had an initial shockable rhythm and remain unresponsive after ROSC. 15
• TTM is suggested for other cardiac‑arrest scenarios when clinically appropriate. 15

Antiarrhythmic Therapy After ROSC

• There is insufficient evidence to support routine initiation or continuation of antiarrhythmic drugs after ROSC; no survival benefit has been demonstrated. 12
• No studies have evaluated amiodarone for post‑ROSC prophylaxis. 13

Neuroprognostication

• Delay prognostication until an adequate interval has passed to avoid confounding from medications or transient neurologic depression. 16
• Perform a multimodal neuroprognostic assessment at ≥ 72 hours after return to normothermia, incorporating clinical exam, serum biomarkers, electrophysiology, and neuroimaging. 16

Special Circumstances

Cardiac Arrest in Pregnancy

• Deliver high‑quality CPR with left lateral uterine displacement to relieve aortocaval compression. 16
• If the fundal height is at or above the umbilicus and ROSC is not achieved, prepare for uterine evacuation while resuscitation continues. 16
• Perimortem cesarean delivery should be initiated within 5 minutes of arrest while BLS/ACLS interventions proceed. 16

Opioid‑Associated Cardiac Arrest

• Do not delay activation of emergency response while awaiting naloxone effect. 16
• In cardiac arrest, prioritize high‑quality CPR over naloxone administration. 16
• Naloxone is indicated for opioid‑related respiratory arrest (IV, IM, sub‑Q, IO, or intranasal routes). 15

Extracorporeal CPR (ECPR)

• ECPR is suggested as a rescue therapy for select patients when conventional CPR fails and the service can be implemented. 15
• Decision to initiate ECPR should consider available resources, personnel expertise, and patient‑selection criteria. 14

Mechanical CPR Devices

• Routine use of automated mechanical chest‑compression devices is not recommended. 15
• They are reasonable alternatives when sustained high‑quality manual compressions are impractical or compromise provider safety. 15

Recovery & Survivorship

• Provide recovery expectations and survivorship plans covering treatment, surveillance, and rehabilitation at hospital discharge. 16
• Address physical, social, emotional, and functional sequelae of cardiac arrest. 16
• Optimize transitions of care to support independent function post‑discharge. 16