Prepared by the LSE Editorial Team. Reviewed by Joseph Andrade, Jr., RN, NRP.
Joseph works across emergency response, healthcare, and workplace safety and develops practical training for civilians, employers, and first responders.
In October 2025, the American Heart Association (AHA) published the 2025 ACLS guidelines as part of its new Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). Part 9 covers Adult Advanced Life Support, and the AHA released a plain-language Highlights document alongside it.
Most of the core stays the same: high-quality CPR, early defibrillation for shockable rhythms, and a team that communicates well. But some details changed, including vascular access, epinephrine timing, refractory ventricular fibrillation (VF), and post-arrest care.
Here is what changed, in plain language, for nurses, paramedics, physicians, and code-team members.
📋 2025 ACLS Guidelines at a Glance
| Topic | What the 2025 guidelines say |
|---|---|
| Vascular access | Try IV first. Intraosseous (IO) is reasonable if IV fails or is not feasible. |
| Epinephrine, shockable rhythms | Reasonable to give after initial defibrillation attempts have failed |
| Vasopressin | No advantage as a substitute for epinephrine |
| Refractory VF/pVT | Vector change and double sequential defibrillation: usefulness not established |
| Head-up CPR | Not recommended outside clinical trials |
| Post-arrest blood pressure | Avoid hypotension; keep mean arterial pressure (MAP) at least 65 mm Hg |
| Temperature control | At least 36 hours for adults who stay unresponsive after return of spontaneous circulation (ROSC), within 32 to 37.5 °C |
| Chain of Survival | One chain for adults and children, in and out of the hospital |
Source: AHA, Highlights of the 2025 AHA Guidelines for CPR and ECC. See the full guideline for the strength of each recommendation.
💉 IV First, Then IO
The 2025 guidelines say health care professionals should first attempt IV access for drug administration in adults in cardiac arrest. IO access is reasonable if IV attempts fail or are not feasible.
For code teams, this is mostly about planning. Decide early who is getting access, and how many IV attempts you will make before going IO, so drug delivery is not delayed.
Epinephrine timing
For shockable rhythms (VF and pulseless ventricular tachycardia, or pVT), the guidelines say it is reasonable to give epinephrine after initial defibrillation attempts have failed. Shocks come first.
The AHA also says vasopressin, alone or combined with epinephrine, offers no advantage as a substitute for epinephrine.
🔗 Related: ACLS Medications: What Learners Should Understand Before Class
⚡ Refractory VF: What the Evidence Supports
Refractory VF is VF that continues after 3 or more shocks. Two techniques have drawn a lot of attention:
- Vector change defibrillation: moving the pads to a different position (new topic in 2025).
- Double sequential defibrillation: two defibrillators shocking close together (updated in 2025).
For both, the 2025 guidelines say the usefulness after 3 or more shocks has not been established. That means the evidence is not strong enough yet to recommend them routinely.
The guidelines also say other antiarrhythmics for shock-refractory VF/pVT, such as beta-blockers, bretylium, procainamide, or sotalol, are of uncertain benefit.
🫀 Tachycardia, Bradycardia, and Cardioversion
Wide-complex tachycardia
Synchronized cardioversion is recommended for unstable patients. It is also recommended for stable patients when vagal maneuvers and medications do not work or cannot be used.
Atrial fibrillation and flutter
For atrial fibrillation, an initial energy of at least 200 joules is reasonable on biphasic devices. For atrial flutter, an initial 200 joules may be reasonable.
Bradycardia
For persistent unstable bradycardia that does not respond to medication, temporary transvenous pacing is reasonable.
🔗 Related: ACLS Rhythm Recognition: What to Know Before Class
🏥 Post-Cardiac Arrest Care After ROSC
Getting a pulse back is the start of the next phase. The 2025 guidelines updated several post-arrest targets:
- Avoid hypotension by keeping MAP at least 65 mm Hg.
- Keep temperature control for at least 36 hours in adults who stay unresponsive to verbal commands, within 32 to 37.5 °C.
- Coronary angiography is recommended before hospital discharge for survivors with a suspected cardiac cause.
- Head-to-pelvis CT and echocardiography or point-of-care ultrasound may be reasonable after ROSC.
- Survivors and caregivers should be assessed for emotional distress before discharge.
👥 Teams, Debriefing, and Special Situations
In-hospital code teams should include members with advanced life support training.
Using both immediate and delayed debriefing is reasonable.
It may be reasonable for health care professionals to use cognitive aids during resuscitation.
Giving an opioid antagonist may be reasonable if it does not interfere with high-quality CPR with breaths.
The guidelines also say routine mechanical CPR devices are not recommended for adult cardiac arrest. They may be considered in settings where manual CPR is difficult or dangerous.
🔗 Related: The Patient Is Already in Cardiac Arrest. Does Naloxone Still Matter?
📚 What This Means for Your ACLS Card
Your current AHA ACLS Provider eCard stays valid until its expiration date. The changes show up in AHA course materials, so your next ACLS course will teach the updated algorithms.
If your card expires soon, compare the ACLS Update / Renewal course with the full ACLS Provider course. If many of these changes are new to you, the full course gives you more practice time.
✅ Key Takeaways
- The 2025 ACLS guidelines say to try IV access first, with IO as the backup.
- For VF and pVT, epinephrine is reasonable after initial shocks fail.
- Vector change and double sequential defibrillation have not been established as useful.
- After ROSC, keep MAP at least 65 mm Hg and maintain temperature control for at least 36 hours when indicated.
- One Chain of Survival now covers adults and children, in and out of the hospital.
- Your current eCard is still valid; your next course will teach the updates.
❓ Frequently Asked Questions
When were the 2025 ACLS guidelines released?
The AHA published the 2025 Guidelines for CPR and Emergency Cardiovascular Care in October 2025. Adult advanced life support is covered in Part 9.
Do I need to retake ACLS because of the 2025 guidelines?
No. Your AHA ACLS Provider eCard stays valid until its expiration date. Your next renewal or provider course will teach the updated content.
Is IO access still allowed in ACLS?
Yes. The 2025 guidelines say to first attempt IV access, and IO access is reasonable if IV attempts fail or are not feasible.
Is double sequential defibrillation recommended in 2025?
The 2025 guidelines say its usefulness after 3 or more shocks for persistent VF or pVT has not been established. Follow your local protocols and medical direction.
What blood pressure target do the 2025 guidelines use after ROSC?
Adults should avoid hypotension after ROSC by keeping a mean arterial pressure of at least 65 mm Hg.
Training You Can Count On. When Seconds Count.
Learn the 2025 Updates Hands-On
Practice the updated algorithms in a live, team-based ACLS class, or bring one onsite for your unit in the Washington, DC region and across the East Coast.
