Defibrillation strategies and airway management

When appropriate expertise is available, manual defibrillation is preferred over automated external defibrillator use due to faster rhythm analysis and treatment. ALS providers must be proficient in both modalities. Defibrillation is recommended even in very fine ventricular fibrillation, as it may result in return of spontaneous circulation (ROSC).¹¹ Advances in extracorporeal CPR include smaller and more mobile veno‑arterial extracorporeal membrane oxygenation (VA‑ECMO) systems, allowing their earlier use in specialized centers and, in selected cases, prehospital settings. Extracorporeal CPR may be considered for selected patients when conventional resuscitation is unsuccessful.¹¹ The importance of regular electrocardiography (ECG) training is emphasized to minimize rhythm misinterpretation and treatment errors. Recommendation regarding initial electrode placement remains unchanged; the electrodes should be placed antero‑lateral, with careful positioning of 1 electrode at the cardiac apex. In refractory shockable rhythms, an anteroposterior defibrillation vector may be considered after 3 unsuccessful shocks.

Effective bag‑mask ventilation is still considered sufficient, with a 2‑person technique preferred. Supraglottic airway placement or endotracheal intubation should not cause significant interruptions to chest compressions and should be performed only by experienced providers. Mechanical ventilation must always be confirmed as effective; otherwise, effective manual ventilation should be resumed. Ventilation efficacy should always be verified by reliable indicators, such as visible chest rise, as inadequate ventilation remains common (particularly during bag‑mask ventilation) and affects survival.¹¹

Physiologically‑guided resuscitation

The 2025 guidelines highlight that a sudden decrease in end‑tidal CO₂ (ETCO₂) may indicate recurrent cardiac arrest or severely reduced cardiac output. Chest compressions should be resumed in adults if systolic blood pressure falls below 50 mm Hg despite interventions. In patients with continuous invasive arterial blood pressure monitoring, small intravenous adrenaline doses (eg, 50–100 µg) are recommended instead of a 1‑mg bolus. If no response occurs after a cumulative dose of 1 mg, extravasation should be excluded before administering additional 1‑mg doses every 3–5 minutes. Target values during resuscitation are equal to or greater than 30 mm Hg for diastolic arterial pressure and equal to or greater than 25 mm Hg (3.3 kPa) for ETCO₂.¹¹

Point‑of‑care ultrasound may be used during ongoing resuscitation by experienced providers to identify potentially reversible causes and to optimize the chest compression technique. Its use must not in any way compromise compression quality or cause delays. Intravenous access is the preferred route for drug administration during cardiac arrest in adults. If intravenous access cannot be rapidly established, intraosseous access is recommended. Routine administration of calcium (strong recommendation against for OHCA and weak recommendation against for in‑hospital cardiac arrest), sodium bicarbonate (weak recommendation against), or corticosteroids during resuscitation is not advised unless there are specific indications for their use.¹¹ Health care systems should establish structured pathways for the aftercare of cardiac arrest survivors and their relatives, covering the continuum from hospital discharge to follow‑up. The care should be multidisciplinary and aligned with the needs of the patients and their families, with appropriate training and ongoing education opportunities for health care professionals. The updated in‑hospital algorithm now clearly differentiates between patients with and without existing circulation.¹¹

Overall, the guidelines emphasize prioritization of high‑quality chest compressions with effective ventilation, early defibrillation, rapid identification and treatment of reversible causes, and administration of adrenaline in nonshockable cardiac arrest.

Determining the cause of cardiac arrest

Early clarification of the underlying etiology is highlighted as a key preventive strategy. In patients with suspected acute coronary syndromes, coronary angiography remains the preferred initial investigation, particularly in the presence of ST‑segment elevation. In patients without ST‑segment elevation, priority is given to comprehensive biphasic whole‑body computed tomography (CT) imaging, including CT pulmonary angiography (eg, to identify hemorrhage or pulmonary embolus). If coronary angiography fails to identify a causative lesion, further neurothoracic imaging is recommended. In the cases of unexplained cardiac arrest, the diagnostic workup has been substantially expanded. The recommended investigations now include toxicological and genetic testing (Brugada syndrome, long QT syndrome), serial 12‑lead ECG, cardiac magnetic resonance imaging (as needed), sodium channel blocker testing (to detect Brugada syndrome), exercise testing, and analysis of data from implantable or wearable monitoring devices. Identification of inherited conditions requires extension of diagnostic evaluation to family members to reduce the risk of OHCA in relatives.¹² Resuscitation‑related injuries should be actively sought (including on CT). Following ROSC, oxygen therapy should initially be delivered at a high concentration and then carefully titrated to avoid both hypo- and hyperoxia. Target oxygen saturation level remains at 94%–98%, corresponding to a partial pressure of arterial oxygen value of 75–100 mm Hg. The updated guidelines explicitly address reduced accuracy of pulse oximetry in individuals with darker skin pigmentation (overestimation). Ventilation strategies continue to aim for normocapnia.¹² Special attention is required in hypothermic patients, in whom hypocapnia may occur more easily. Blood gas analysis should therefore be interpreted accordingly, using either temperature‑corrected or uncorrected values. Most intensive care recommendations from earlier versions of the guidelines remain valid. Comatose patients should undergo airway protection with endotracheal intubation performed by experienced clinicians. Initial mechanical ventilation may begin with 100% oxygen, followed by rapid adjustment once reliable oxygenation measurements are available. Hypoxia must be strictly avoided. Postarrest hemodynamic management prioritizes the prevention of hypotension, with a target mean arterial pressure value above 60–65 mm Hg. Volume therapy, vasopressors, and inotropes should be selected according to individual hemodynamic requirements. Routine corticosteroid administration is discouraged. In selected patients with favorable prognostic indicators and persistent cardiogenic shock or recurrent malignant ventricular arrhythmias, escalation to mechanical circulatory support may be appropriate if pharmacological therapy proves insufficient. Available options include intra‑aortic balloon counterpulsation, ventricular assist devices, and VA‑ECMO.¹² Management of periarrest arrhythmias has been revised. Prophylactic antiarrhythmic medication is no longer recommended in the patients who remain free of arrhythmias after ROSC. Standard intensive care measures continue to apply, including cautious use of antibiotics, preference for short‑acting sedatives, avoidance of routine neuromuscular blockade, head‑of‑bed elevation, stress ulcer prophylaxis, maintenance of normoglycemia, seizure management, and deferral of neurological prognostication for at least 72 hours.¹²

Temperature control and neurological recovery

The concept of temperature control has replaced earlier terminology related to targeted temperature management. In comatose patients, active prevention of fever is recommended, with body temperature maintained at or below 37.5 °C for 36–72 hours after ROSC. Patients who present with mild spontaneous hypothermia (32–36 °C) should not be actively rewarmed. Prehospital cooling using large volumes of cold intravenous fluids is no longer advised. The benefit of inducing moderate hypothermia (32–34 °C) in specific patient groups remains uncertain, as such groups have not yet been clearly identified. While ERC recommendations are cautious in this regard, recent Cochrane data suggest a significant neurological benefit without increased adverse events with therapeutic hypothermia at 32–34 °C for at least 24 hours, and the topic remains controversial.¹² Continuous electroencephalography (EEG) monitoring remains central for the detection of subclinical seizures. Antiepileptic therapy should be initiated only in the presence of clinical or electrographic seizure activity, with levetiracetam or sodium valproate recommended alongside sedation. The guidelines newly emphasize that awakening attempts may be appropriate in patients with posthypoxic myoclonus and a benign EEG pattern several days after cardiac arrest. Multimodal prognostication remains the cornerstone of outcome assessment. While individual tests may be initiated earlier, final prognostic conclusions should not be drawn earlier than 72 hours after cardiac arrest, and only in the absence of confounding factors.¹² A poor neurological outcome is considered likely only when multiple unfavorable predictors are present, including absent brainstem reflexes, bilaterally absent N20 responses, highly malignant EEG patterns, sustainably elevated and / or increasing neuron‑specific enolase levels, persistent status myoclonus, or extensive anoxic brain injury on neuroimaging. Decisions regarding withdrawal of life‑sustaining treatment must be clearly separated from neurological outcome prediction. Such decisions should integrate neurological findings with patient age, comorbidities, overall organ function, and documented patient preferences. Transparent communication within the care team and with relatives is essential.¹²

Rehabilitation, follow‑up, and long‑term outcomes

Postdischarge care has been strengthened through expanded recommendations on rehabilitation and structured follow‑up. Early rehabilitation measures initiated in the intensive care unit (ICU), including mobilization, delirium prevention strategies, and ICU diaries, are encouraged. Optimally, prior to discharge, patients should undergo a comprehensive evaluation of physical, cognitive, and psychological sequelae to guide personalized rehabilitation planning. Assessment of neurological recovery is no longer limited to conventional outcome scales but should include more detailed functional evaluations before discharge and during the first 3 months thereafter. Relatives are to be actively involved throughout both diagnostic clarification and the rehabilitation process.¹² The guidelines recommend systematic consideration of organ donation in all patients approaching end of life. In comatose, ventilated patients after cardiac arrest, the possibility of organ donation should be integrated into end‑of‑life decision‑making. All organ donations following resuscitation should be documented in national resuscitation registries. For example, in Germany, organ donation after cardiac arrest requires formal confirmation of brain death, making early initiation of brain death diagnostics essential. Other countries apply different legal standards for donation after circulatory death.¹²