ERC Guidelines 2025: The Key Changes for Clinical Practice

Resuscitation 2025: Overview of Changes

The ERC Guidelines 2025 provide an updated European standard for basic life support, advanced life support and post-resuscitation care. This article focuses on:

• Adults (ALS): Specifications for the ALS algorithm, covering compression quality, shock counting, defibrillation, airway and post-resuscitation care.
• Newborns (NLS): The guideline explicitly identifies what has changed since 2021.
• Children (PLS): The paediatric recommendations are not discussed in detail here. The relevant chapter of the ERC Guidelines 2025 applies.

Adults: The ALS Algorithm 2025

Quality of Chest Compressions

The foundation remains unchanged: high-quality chest compressions with minimal interruptions. According to ERC 2025:

• Hand position: centre of the chest (lower half of the sternum)
• Depth: 5–6 cm
• Rate: 100–120/min
• Recoil: complete, with the hands remaining on the chest
• Ratio: 30:2. With a tracheal tube or supraglottic airway (SGA), compressions are continuous, with 10 ventilations/min. If there is a significant leak from the SGA, revert to 30:2.
• Pre-shock pause: as short as possible (< 5 s). Compressions continue while the defibrillator charges.
• Change of compressor: every 2 min, at each rhythm analysis

Drugs: Timing Depends on the Number of Shocks

The ALS algorithm runs in 2-minute cycles with rhythm analysis. According to ERC 2025, drugs are given as follows:

As an alternative to amiodarone, lidocaine 100 mg or 50 mg may be given. Two clarifications are relevant to practice:

• Total number of shocks: Amiodarone doses are based on the total number of shocks delivered (3 and 5 respectively). It does not matter whether ventricular fibrillation is persistent or recurrent.
• Witnessed and monitored arrest, for example in the cardiac catheterisation laboratory: up to three shocks may be delivered in rapid succession. For the timing of adrenaline and amiodarone, this series of three counts as one shock.

Defibrillation and Refractory Ventricular Fibrillation

• Biphasic (rectilinear or truncated exponential): first shock at least 150 J.
• Pulsed biphasic: first shock 130–150 J.
• Unsuccessful shock: if the device allows, increase the energy for subsequent shocks. If the recommended setting is unknown, use the highest energy for all shocks.
• Refractory VF (persisting after 3 shocks): first check correct pad placement, then consider changing the vector to anterior–posterior.
• Double sequential defibrillation with a second device (anterior–lateral and anterior–posterior): the evidence is weak. ILCOR 2025 considers the technique a possible option in refractory VF.

Access, Airway and Capnography

• Access: intravenous first. Intraosseous if IV access cannot be obtained rapidly.
• Stepwise airway approach: bag-mask, then SGA or intubation. Intubation is indicated only where there is a high success rate (> 95% within ≤ 2 attempts) and the compression pause remains under 5 s.
• Waveform capnography is mandatory. It is used to confirm tube placement and assess compression quality, and a sudden rise in etCO₂ may indicate ROSC. A low etCO₂ alone is not a criterion for terminating resuscitation.
• Oxygen: at the highest possible concentration during resuscitation.

Reversible Causes, POCUS and eCPR

The search for reversible causes continues to follow the "4 Hs and 4 Ts" approach:

• 4 Hs: hypoxia, hypovolaemia, hypo-/hyperkalaemia or metabolic disorders, hypo-/hyperthermia
• 4 Ts: cardiac tamponade, toxins, thrombosis (coronary, pulmonary), tension pneumothorax

Point-of-care ultrasound should only be used by skilled operators and without additional interruptions to compressions. In selected patients, eCPR may be considered as a rescue therapy when conventional measures fail and a system is available. It is important to consider it early.

After ROSC: Targets

The joint ERC and ESICM guideline on post-resuscitation care specifies the following targets:

Children: PLS

The paediatric recommendations of the ERC Guidelines 2025 are outside the scope of this overview. For doses and the algorithm, refer to the PLS chapter of the guideline.

One point of overlap with newborn care is relevant to practice: in the prehospital setting, either the NLS or the PLS algorithm may be used for newborns. The more familiar one is recommended. Switching is possible if needed, and help should be called for early.

Newborns: Changes Since 2021

For newborn resuscitation, the ERC Guidelines 2025 explicitly identify the changes. Most newborns require nothing more than effective ventilation.

Ventilation and Oxygen

• Initial oxygen now in only two categories: ≥ 32 weeks' gestation with 21% (room air), < 32 weeks' gestation with ≥ 30%.
• PEEP and CPAP uniformly 6 cmH₂O. Spontaneously breathing preterm infants < 32 weeks' gestation with respiratory distress receive CPAP 6 cmH₂O as initial respiratory support.
• Inflation breaths: 5 × with an inspiratory time of up to 2–3 s. The initial pressure is 30 cmH₂O (≥ 32 weeks' gestation) or 25 cmH₂O (< 32 weeks' gestation). These are followed by 30 ventilations/min with an inspiratory time of approximately 1 s. Inflation manoeuvres last no longer than 5 s.
• SpO₂ target ranges from minute 3 (preductal, right hand): 70–75% at minute 3, 80–85% at minute 5, 85–95% at minute 10. If SpO₂ is > 95%, reduce the oxygen.

Airway and Monitoring

• Two-person technique with jaw thrust: preferred when sufficient staff are available.
• Early laryngeal mask: if mask ventilation is ineffective, or as the primary device instead of the face mask if the size is appropriate. Data are available mainly from 34 weeks' gestation.
• Videolaryngoscope: part of the intubation set, with the direct laryngoscope as backup.
• ECG as the most accurate heart rate measurement: the stethoscope is acceptable as a first step. Skin colour is of secondary importance only, as it is subjective and unreliable depending on skin tone.
• No routine suctioning, including in the presence of meconium. If the infant is not breathing, ventilate immediately.

If the heart rate does not rise after the inflation breaths, ventilation is almost always ineffective. Check head position, mask seal and chest rise. Only then escalate.

Chest Compressions and Drugs

• Chest compressions: if HR < 60/min despite at least 30 s of effective ventilation. Use the two-thumb technique at a ratio of 3:1, with oxygen at 100%.
• Adrenaline IV/IO: 10–30 µg/kg, standard according to RCUK 20 µg/kg, corresponding to 0.2 ml/kg of the 0.1 mg/ml solution. Repeat doses are uniformly every 4 min while HR remains < 60/min.
• Adrenaline endotracheal: 100 µg/kg, only in an intubated infant without vascular access. As soon as access is established, give the IV/IO dose immediately.
• Volume: 10 ml/kg isotonic crystalloid or O RhD-negative packed red cells, no albumin.
• Glucose 10%: 2 ml/kg, only for measured hypoglycaemia.
• Sodium bicarbonate: removed from resuscitation.

Cord Clamping and Temperature

• Stabilisation with an intact umbilical cord is preferred where this can be done safely, especially < 34 weeks' gestation.
• No umbilical cord milking < 28 weeks' gestation.
• Temperature target 36.5–37.5 °C. Preterm infants < 32 weeks' gestation are placed in plastic wrapping without drying the body; the head is dried and covered with a hat. The admission temperature must be documented.

After Resuscitation

In moderate to severe hypoxic-ischaemic encephalopathy from 36 weeks' gestation, therapeutic hypothermia is indicated: 33–34 °C for 72 h, started within 6 h. It is performed only in a specialist centre according to a defined protocol. Transfer should be discussed early; until then, hyperthermia must be avoided.

If no heart rate is detectable more than 20 min after birth despite all recommended measures and after exclusion of reversible causes, discontinuation is discussed within the team and with the parents.

Practical Summary

• ALS: Compression quality and short pauses remain central. Drug administration in shockable rhythms is based on the total number of shocks. In refractory VF, check pad placement and then change the vector. Capnography is mandatory.
• Post-ROSC: Normoxaemia, normocapnia and fever prevention for at least 72 h in comatose patients.
• NLS: two initial oxygen categories, uniform PEEP of 6 cmH₂O, SpO₂ targets from minute 3, adrenaline repeated every 4 min, no more sodium bicarbonate.
• PLS: check details in the relevant guideline chapter.

Local standards, emergency cards and simulation training should be reviewed against these points.

References

• Soar J, Böttiger BW et al. European Resuscitation Council Guidelines 2025 Adult Advanced Life Support. Resuscitation 2025;215 Suppl 1:110769 (Korrigendum 2026).
• Nolan JP, Sandroni C et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2025 Post-Resuscitation Care. Resuscitation 2025 / Intensive Care Med 2025;51:2213–2288.
• Kurzfassung der Leitlinien des European Resuscitation Council 2025. Notfall Rettungsmed 2025.
• Hogeveen M, Monnelly V, Binkhorst M et al. European Resuscitation Council Guidelines 2025 Newborn Resuscitation and Support of Transition of Infants at Birth. Resuscitation 2025;215 Suppl 1:110766.
• Resuscitation Council UK. Newborn resuscitation and support of transition of infants at birth – 2025 Resuscitation Guidelines (nationale Adaptation der ERC-Leitlinien 2025).

This article does not replace clinical judgement in the individual case or the current summary of product characteristics and guidelines.