Adult cardiac arrest, 2025 AHA.
Adult arrest and peri-arrest care per the 2025 AHA guidelines: shockable and nonshockable sequences, doses and energies, airway, bradycardia, tachycardia, post-ROSC targets, special cases and stopping.
Reviewed October 2026 · verify against current guidelines
Running a code now — open the adult code companion: wall-clock timers, 2-minute cycle prompts, epinephrine due window, one-tap event log, and bradycardia, tachycardia and post-ROSC modes. Scope: adults, per the 2025 AHA Guidelines for CPR and ECC (published October 22, 2025). A study and recall aid: not an AHA product, and not a substitute for certified AHA training or your hospital's protocol.
Adult code · 1 of 6
Compress, check, shock.
Every arrest, first minute
| Recognize | Unresponsive, not breathing or only gasping, no definite pulse within 10 seconds: treat as cardiac arrest. |
|---|---|
| Start | Compressions first. Oxygen by bag-mask. Pads on the chest the moment a defibrillator arrives. |
| Decide | One question at each rhythm check: shockable (VF or pulseless VT) or not (asystole or PEA)? |
Shockable: VF or pulseless VT
| Shock 1 | Shock, then straight back on the chest. Two minutes of CPR. Get IV access. |
|---|---|
| Shock 2 | Shock, two minutes of CPR. Initial shocks have failed, so start epinephrine 1 mg, repeated every 3 to 5 minutes. This is a good moment for an advanced airway with waveform capnography. |
| Shock 3 | Shock, two minutes of CPR. Add amiodarone or lidocaine, and work through the reversible causes. |
| Then | Keep cycling: rhythm check, shock if shockable, CPR, epinephrine on schedule. If the rhythm turns nonshockable, switch tracks. Defibrillation comes before drugs: the 2025 text supports epinephrine in shockable rhythms only after initial shocks fail. |
Nonshockable: asystole or PEA
| Now | Epinephrine 1 mg as soon as feasible. Two minutes of CPR. Get IV access. |
|---|---|
| Every cycle | Repeat epinephrine every 3 to 5 minutes. Secure the airway with capnography once CPR is running well. Hunt for the cause. |
| At each check | Shockable now? Shock and follow the shockable track. Organized rhythm? Pulse check. No pulse: back to CPR. Pulse: post-arrest care. |
High-quality CPR
| Depth | At least 2 in (5 cm); avoid more than 2.4 in (6 cm). |
|---|---|
| Rate | 100 to 120 per minute. Full recoil: do not lean. |
| Hands | Heel of one hand on the lower half of the sternum, other hand on top. Patient's torso at about the level of your knees. |
| Pauses | Pulse checks no more than 10 seconds. Keep pre- and post-shock pauses as short as possible. Resume compressions right after the shock, without a post-shock rhythm check. |
| Fraction | Aim for a chest compression fraction of at least 60%. |
| Breaths | No advanced airway: 30:2, each breath over 1 second, just enough for visible chest rise. Advanced airway: 1 breath every 6 seconds (10/min) with continuous compressions. |
| Compressors | Swap at each 2-minute check, earlier if depth drops. |
| Pads | Anterolateral or anteroposterior. You may move a bra rather than remove it. |
VF / pVT ventricular fibrillation / pulseless ventricular tachycardiaPEA pulseless electrical activityCPR cardiopulmonary resuscitationIV / IO intravenous / intraosseousETCO2 end-tidal carbon dioxideROSC return of spontaneous circulationILCOR International Liaison Committee on ResuscitationLOE level of evidence
Adult code · 2 of 6
Doses, joules, routes.
Arrest drugs (IV or IO)
| Epinephrine | 1 mg every 3 to 5 minutes (Class 2a). In practice: every second 2-minute cycle after the first dose. High-dose epinephrine is not recommended (Class 3: No Benefit). |
|---|---|
| Amiodarone | For VF/pVT unresponsive to shocks (Class 2b). 300 mg bolus, then 150 mg. |
| Lidocaine | The alternative to amiodarone (Class 2b). 1 to 1.5 mg/kg, then 0.5 to 0.75 mg/kg. The data cannot separate the two drugs or support combining them. |
| Vasopressin | No advantage alone or added to epinephrine (Class 3: No Benefit). |
| Not routine | Calcium, sodium bicarbonate and magnesium are not recommended routinely (Class 3: No Benefit). Steroids: uncertain benefit. β-blockers, bretylium, procainamide and sotalol for refractory VF/pVT: uncertain benefit. |
Shock energy
| Biphasic, shock 1 | The manufacturer's recommended dose (for example, 120 to 200 J). Unknown? Use the maximum available. |
|---|---|
| Biphasic, later shocks | Equivalent energy; higher energy may be considered on devices that escalate (Class 2b). |
| Monophasic | 360 J. |
| Strategy | Single shocks, not stacked (Class 2a). Biphasic is preferred over monophasic (Class 2a). |
| Persisting VF | After 3 or more shocks, vector change and double sequential defibrillation remain unproven (Class 2b: usefulness not established). Check pad contact and position first. |
Access
| First | Peripheral IV (Class 1, LOE A). |
|---|---|
| If IV fails | IO is reasonable (Class 2a, LOE A). An ILCOR review found lower odds of sustained ROSC with IO than IV. |
| Then | Central venous access by trained hands may be considered (Class 2b) if IV and IO fail. Do not stop compressions for it. |
| Gone | Drugs down the endotracheal tube were removed from the 2025 guidelines. |
| Pacing | Routine electrical pacing during established arrest is not recommended (Class 3: No Benefit). Exception: wires already in after cardiac surgery (section 6). |
Adult code · 3 of 6
Airway, CO₂, causes.
Advanced airway
| Timing | If placing it will interrupt compressions, wait until initial CPR and shocks fail or ROSC occurs (Class 1). In nonshockable arrest, earlier airway work is possible once CPR and epinephrine are running well. |
|---|---|
| Device | Bag-mask or an advanced airway, depending on setting and skill (Class 2b). In hospital, an expert can use either a supraglottic airway or an endotracheal tube (Class 2a). |
| Confirm | Continuous waveform capnography plus clinical assessment is the most reliable way to confirm and monitor tube position (Class 1). |
| Oxygen | Use the highest feasible inspired oxygen during CPR (Class 2b). |
| Ultrasound | Point-of-care ultrasound to find reversible causes: not well established (Class 2b). If an experienced operator uses it, it must not interrupt CPR. Echo to predict outcome during arrest: not well established (Class 2b). |
| Head-up CPR | Not recommended outside clinical trials (Class 3: No Benefit). |
Reading ETCO<sub>2</sub> during CPR
| Under 10 mm Hg | Generally linked to poor outcomes. Fix CPR quality first: depth, rate, recoil, compressor fatigue. |
|---|---|
| 10 to 20 mm Hg and up | At least 10, ideally 20 or more, suggests mechanically adequate compressions. |
| Abrupt rise | May signal ROSC (Class 2b). A sudden jump of more than 10 mm Hg is suggestive, but ROSC can happen with smaller rises. |
| Confounders | Minute ventilation, epinephrine or bicarbonate, airway type and the cause of arrest all move the number. |
Reversible causes: run the list every cycle
- Low oxygen.
- Low volume or bleeding.
- Acidosis.
- Potassium too high or too low.
- Too cold.
- Pneumothorax under tension.
- Fluid compressing the heart (tamponade).
- Clot in the lungs (pulmonary embolism).
- Clot in a coronary artery.
- A drug or poison.
Adult code · 4 of 6
Too slow, too fast.
One question first
Is the rate causing the instability, or is it a response to something else (sepsis, hypoxia, bleeding)? The 2025 guidelines put this first. Signs that the rhythm is to blame: hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, acute heart failure.
Bradycardia with a pulse (typically under 50/min)
| Everyone | Find the driver while you support the patient: monitor, IV, 12-lead, oxygen only if needed. Usual suspects: ischemia, AV-nodal drugs (β-blockers, calcium channel blockers, digoxin), low oxygen, high potassium (Class 1). |
|---|---|
| Compromised | Atropine 1 mg IV, repeat every 3 to 5 minutes, maximum 3 mg total (Class 2a). |
| Atropine fails | Pace through the pads, or start a chronotropic drip: dopamine 5 to 20 mcg/kg/min or epinephrine 2 to 10 mcg/min, titrated (Class 2b). |
| Still unstable | Call cardiology for a temporary transvenous pacing wire (Class 2a). |
| No IV or IO | In unstable high-degree AV block, immediate pacing might be considered (Class 2b). |
Tachycardia with a pulse (typically 150/min or more)
| Unstable | Cardiovert, synchronized. Sedate if the patient is aware and time allows. A narrow, regular rhythm may break with adenosine while you set up. At 150/min or less, the rhythm is unlikely to be the cause: look for another driver first. |
|---|---|
| Starting energy | Atrial fibrillation 200 J; atrial flutter 200 J; other narrow-complex tachycardia 100 J; monomorphic VT 100 J. Or use the device's recommended level; if unknown, the maximum. |
| Polymorphic VT | Always unstable. Unsynchronized, maximum-energy shock now (Class 1). |
| Stable, narrow, regular | Vagal maneuvers (Class 1), then adenosine 6 mg rapid IV push with a saline flush, then 12 mg (Class 1). Adenosine is contraindicated in asthma; with a central line or after heart transplant, 1 mg may be enough. IV diltiazem or verapamil can work (Class 2a); IV β-blockers are generally safe. |
| Stable, wide | Adenosine is an option only for a regular, monomorphic rhythm (Class 2b). Otherwise infuse amiodarone, procainamide or sotalol (Class 2b) and bring in cardiology. Keep the defibrillator at the bedside. |
| Procainamide | 20 to 50 mg/min, never faster than 50. Stop at 17 mg/kg, or sooner if the rhythm breaks, blood pressure falls or QRS widens by more than 50%. Maintenance 1 to 4 mg/min. Avoid with long QT or heart failure. |
| Amiodarone (stable VT) | 150 mg over 10 minutes, repeat if VT recurs, then 1 mg/min for the first 6 hours. |
| Never | Verapamil or diltiazem in wide-complex tachycardia (Class 3: Harm). Adenosine in unstable, irregular or polymorphic wide-complex tachycardia (Class 3: Harm). |
| Torsades | Magnesium may be considered for recurrent polymorphic VT with a long QT (Class 2b); correct hypokalemia. With a normal QT, magnesium is not recommended (Class 3: No Benefit): treat ischemia and consider lidocaine or amiodarone. No magnesium dose is given in the 2025 text. |
Atrial fibrillation or flutter with rapid rate: IV rate control
| Diltiazem | 0.25 mg/kg over 2 min; infusion 5 to 10 mg/h. Avoid in hypotension, heart failure, cardiomyopathy and acute coronary syndromes. |
|---|---|
| Verapamil | 0.075 to 0.15 mg/kg over 2 min; another dose after 30 min if no response; infusion 0.005 mg/kg/min. Same cautions as diltiazem. |
| Metoprolol | 2.5 to 5 mg over 2 min, up to 3 doses. |
| Esmolol | 500 mcg/kg over 1 min; infusion 50 to 300 mcg/kg/min. |
| Amiodarone | 300 mg over 1 h, then 10 to 50 mg/h over 24 h. Useful in the critically ill (Class 2a). |
| Digoxin | 0.25 mg IV, repeated to 1.5 mg in 24 h. Slow; usually an add-on. Caution in kidney disease. |
| Pre-excitation | No digoxin, calcium channel blockers, β-blockers or IV amiodarone (Class 3: Harm). Cardiovert. |
| Decompensated HFrEF | No nondihydropyridine calcium channel blockers or IV β-blockers (Class 3: Harm). |
Adult code · 5 of 6
After ROSC, protect the brain.
Targets
| Oxygen | Start at 100% FiO2 (Class 1). Once SpO2 or PaO2 is trustworthy, titrate to SpO2 90% to 98% or PaO2 60 to 105 mm Hg (Class 2a). Oximetry can hide hypoxemia in darker skin. |
|---|---|
| CO2 | PaCO2 35 to 45 mm Hg (Class 1). Check a blood gas: ETCO2 may read falsely low after arrest. |
| Pressure | MAP at least 65 mm Hg (Class 1). No preferred vasopressor. |
| Glucose | Avoid below 70 mg/dL and above 180 mg/dL (Class 2b). |
| Temperature | Not following commands: deliberate temperature control at 32 to 37.5 °C (Class 1) for at least 36 hours (Class 2a). Avoiding rewarming faster than 0.5 °C/h may be reasonable (Class 2b). No routine prehospital cold IV fluids. |
Find the cause
| ECG | 12-lead as soon as feasible (Class 1). Very early post-ROSC ECGs have more false-positive STEMI patterns; repeat it. |
|---|---|
| Imaging | Head-to-pelvis CT (Class 2b) and echocardiography or point-of-care cardiac ultrasound (Class 2b) may be reasonable. |
| Cath lab now | Persistent ST elevation with a suspected cardiac cause, regardless of coma (Class 1). Reasonable without ST elevation if there is cardiogenic shock, recurrent ventricular arrhythmias or ongoing ischemia (Class 2a). |
| Cath lab later | Comatose and stable without those features: emergency angiography is not better than a delayed or selective strategy (Class 3: No Benefit). Angiography before discharge if a cardiac cause is suspected (Class 1). |
| Seizures | EEG promptly in anyone not following commands (Class 1). Treat clinical and EEG-only seizures. No routine prophylaxis. Do not treat myoclonus that has no EEG correlate. |
| Prognosis | Multimodal, never a single finding (Class 1). Consolidate at least 72 hours after normothermia and off sedation (Class 2a); Part 11 (section 14.2) notes this is typically at least 5 days after ROSC when hypothermic temperature control was used. Talk with surrogates early and often. |
FiO2 fraction of inspired oxygenMAP mean arterial pressureSTEMI ST-elevation myocardial infarctionEEG electroencephalographyAV atrioventricularVT ventricular tachycardiaHFrEF heart failure with reduced ejection fractionQRS ventricular depolarization complexECPR / ECLS extracorporeal CPR / extracorporeal life supportEMS emergency medical servicesBLS / ALS basic / advanced life supportICU intensive care unit
Adult code · 6 of 6
When the algorithm bends.
Special circumstances with specific 2025 actions
| Pregnancy | Call the obstetric arrest team. If the fundal height is at or above the umbilicus: continuous manual left uterine displacement, and prepare for resuscitative delivery from the moment of arrest, aiming to deliver by 5 minutes, where the arrest happened (Class 1). Get the airway early, by the most skilled operator. Lines go above the diaphragm. Magnesium running? Turn it off and give calcium. Fetal monitors come off. ECPR is reasonable if standard resuscitation fails (Class 2a). |
|---|---|
| Opioids | Respiratory arrest with a pulse: ventilate and give an opioid antagonist such as naloxone (Class 1). In cardiac arrest, naloxone may be reasonable only if it does not interrupt high-quality CPR with breaths (Class 2b). Part 10 Table 4 adult naloxone dose: 0.2 to 2 mg IV, IO or IM, or 2 to 4 mg intranasal, repeated every 2 to 3 minutes as needed. |
| Hyperkalemia | In arrest, calcium, sodium bicarbonate and insulin-glucose are all of unproven effect (Class 2b). The 2025 table lists 10 units of regular insulin IV over 15 to 30 minutes with 50 g dextrose (D50) if used. Inhaled β2-agonists are not recommended. |
| Hypothermia (under 30 °C) | Resuscitate fully while rewarming; ECLS rewarming is reasonable (Class 2a). Shocks: one shock; if it fails, holding further shocks until 30 °C or above may be reasonable (Part 10 Rec 5, Class 2b). Epinephrine: holding it until 30 °C or above may be reasonable (Part 10 Rec 7, Class 2b). No 2025 recommendation on antiarrhythmics in hypothermic arrest. ETCO2 does not predict outcome here. |
| Pulmonary embolism | Confirmed: fibrinolysis, surgical or percutaneous embolectomy are reasonable (Class 2a). Suspected: fibrinolysis may be considered (Class 2b). ECLS is reasonable. How long to continue CPR after a lytic is unclear. |
| Local anesthetic toxicity | Give 20% lipid emulsion (Class 1). Part 10 Table 4: under 70 kg, 1.5 mL/kg, then 0.25 mL/kg/min for up to 30 minutes; over 70 kg, 100 mL over 2 to 3 minutes, then 200 to 250 mL over 15 to 20 minutes. Benzodiazepines for seizures. Sodium bicarbonate for wide-complex tachycardia is reasonable. |
| Sodium channel blockers | Sodium bicarbonate for tricyclic cardiotoxicity (Class 1). |
| After cardiac surgery | External chest compressions if emergency resternotomy is not immediately available (Class 1). Witnessed VF: up to 3 stacked shocks immediately, CPR if not converted within 1 minute (Class 1). Asystole or a bradycardic arrest with wires in: pace, CPR within 1 minute if it fails (Class 1). Rapid resternotomy in an equipped ICU is reasonable (Class 2a). |
Stopping: Part 9, Termination of Resuscitative Measures (recs 1 to 5)
| Rec 1 to 3 | Out-of-hospital rules matched to EMS scope: BLS rule (Class 1), ALS rule (Class 2a), universal rule in tiered systems (Class 2a). |
|---|---|
| Not for the ward | The 2025 text calls these rules inappropriate where they were not validated, including in-hospital arrest, overdose and trauma. |
| Rec 4 | Intubated: ETCO2 never above 10 mm Hg after 20 minutes of ALS may be one part of a multimodal decision (Class 2b). |
| Rec 5 | Not intubated: no ETCO2 cutoff should be used to stop (Class 3: Harm). |
| Also | A high ETCO2 late in a code is not, alone, a reason to continue. Never stop on ETCO2 alone. |
Common errors
- Pulse checks that drift past 10 seconds, or a rhythm check right after the shock.
- Epinephrine before the first shock in VF.
- Stacking shocks outside the post-cardiac-surgery exception.
- Hyperventilating: more than 10 breaths per minute once the airway is in.
- Pausing compressions to intubate in a shockable arrest.
- Adenosine in irregular or polymorphic wide-complex tachycardia; diltiazem or verapamil in any wide-complex tachycardia.
- Cardioverting a sinus tachycardia that is compensating for sepsis or bleeding.
- Routine calcium or bicarbonate with no specific indication.
- Using an out-of-hospital termination rule, or ETCO2 alone, to stop an in-hospital code.
- Leaving FiO2 at 100% after ROSC once SpO2 is reliable, or calling a prognosis on day 1.
Marked as new or changed in the 2025 text — AF and flutter cardioversion start at 200 J (Part 9 notes earlier guidelines deferred to the manufacturer). Endotracheal drug delivery was removed. Termination guidance was updated: rules matched to EMS scope, and ETCO2 never used alone. After ROSC, the earlier systolic target was removed in favor of MAP of at least 65. Part 11 also updated temperature control, mechanical support, coronary angiography and ventilation goals, and added a section on myoclonus. In pregnancy, "resuscitative delivery" replaces "perimortem cesarean delivery", with preparation starting when the arrest is recognized; the 4- to 5-minute interval itself dates from 1986.
Educational reference only — not medical advice. Not affiliated with or endorsed by the American Heart Association, and not a substitute for certified AHA training. Verify against current AHA guidelines and local protocol.
Sources
Verify against current guidelines and local protocol before acting.
- Wigginton JG, Agarwal S, Bartos JA, et al. Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2025;152(16 Suppl 2):S538-S577. Published October 22, 2025. doi:10.1161/CIR.0000000000001376. Online: cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-advanced-life-support
- American Heart Association. 2025 algorithm text: Adult Cardiac Arrest Algorithm; Adult Bradycardia With a Pulse Algorithm; Adult Tachyarrhythmia With a Pulse Algorithm; Electrical Cardioversion Algorithm; Adult Post-Cardiac Arrest Care Algorithm; Cardiac Arrest in Pregnancy Algorithm; BLS/Universal and ALS Termination of Resuscitation Rules. cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms. Facts restated in our own words; figures not reproduced.
- Kleinman ME, Buick JE, Huber N, et al. Part 7: Adult Basic Life Support: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S448-S478. doi:10.1161/CIR.0000000000001369.
- Cao D, Arens AM, Chow SL, et al. Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S578-S672. doi:10.1161/CIR.0000000000001380.
- American Heart Association. 2025 Part 10, Table 3 (insulin-glucose dosing for cardiac arrest from suspected hyperkalemia) and Table 4 (commonly used doses of antidotes for resuscitation in critical poisoning). cpr.heart.org, adult-and-pediatric-special-circumstances-of-resuscitation.
- Hirsch KG, Amorim E, Coppler PJ, et al. Part 11: Post-Cardiac Arrest Care: 2025 AHA Guidelines for CPR and ECC. Circulation 2025;152(16 Suppl 2):S673-S718. doi:10.1161/CIR.0000000000001375.
- American Heart Association. Highlights of the 2025 AHA Guidelines for CPR and ECC (items labeled new or updated). cpr.heart.org.
- Not affiliated with or endorsed by the AHA. Not a substitute for certified AHA resuscitation training.