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Understanding the 2026 ILCOR Guidelines for CPR, ECC, and First Aid

by  Bob Elling     Nov 20, 2025
2026-ilcor-guidelines

This time of year often brings "guidelines fever," but it's important not to overreact. The key is to understand the process and evaluate the strength of the recommendations. 

In reviewing the ILCOR Consensus on Science with Treatment Recommendations (CoSTR) from the 10/22/25 Circulation supplement, I have found there are few changes impacting lay rescuers, first aid providers, and most prehospital EMS providers. The document contains few "strongly recommended" actions and even fewer based on "high certainty of evidence." Most are "good practice statements." Let's explore the highlights.

What is ILCOR? 

The International Liaison Committee on Resuscitation (ILCOR), established in 1992, serves as a global forum for resuscitation organizations. Comprising 10 resuscitation councils, ILCOR aims to save more lives worldwide through resuscitation. They focus on promoting, disseminating, and advocating for the international implementation of evidence-based resuscitation and first aid, using transparent evaluation and consensus on scientific data. ILCOR operates through six Task Forces. 

  • Basic Life Support (BLS)
  • Advanced Life Support (ALS)
  • Pediatric Life Support (PLS)
  • Neonatal Life Support (NLS)
  • Education, Implementation, and Teams (EIT)
  • First Aid

The CoSTR document features an Executive Summary, details on the evidence evaluation process, conflict of interest management, and chapters from each of the six Task Forces with updates from the past year. It also summarizes topics reviewed since 2020, making it a comprehensive 5-year update.

ILCOR’s Process

The guidance is supported by three approaches: systematic review (SysRev), scoping review (ScopRev), and evidence update (EvUps). The systematic review, the most detailed, starts by identifying topics and formulating questions using the PICOST framework (population, intervention, comparator, outcome, study design, and time frame). Detailed steps are in the methodology section. After thorough review, task forces reach a consensus on science to make treatment recommendations based on recommendation strength and evidence certainty. Sometimes, a good practice statement is made despite limited evidence. 

If you have time, I recommend reviewing the entire document. If not, I've highlighted the new 2025 updates for each Task Force, along with other recommendations since 2020 not listed here.

Click below to see updates for each specific Task Force:

BLS Evidence 2025 Updates

  • AED Accessibility (Locked Cabinets) – Advise against using locked cabinets for public access defibrillator storage (good practice statement).

    • If locked cabinets are used, ensure instructions for unlocking are clear and minimize access delays (good practice statement).

    • EMS should devise strategies to return public access defibrillators when used (good practice statement).

  • CAB vs ABC in Drowning: CPR – Recommend a compression-first strategy (CAB) for laypeople providing resuscitation for adults in cardiac arrest caused by drowning (good practice statement).

    • Health care professionals and those trained with a duty to respond to drowning (e.g., lifeguards) should consider providing rescue breaths/ventilation first (ABC) before chest compressions (good practice statement).

  • CPR in Obese Patients – Standard CPR protocols should be used in obese patients (good practice statement). 

ALS Evidence 2025 Updates

  • Mechanical CPR Devices – Suggest against the routine use of automated mechanical chest compression devices to replace manual chest compressions for out-of-hospital cardiac arrest (weak recommendation, low-certainty evidence).

  • Automated mechanical chest compression devices may be a reasonable alternative to manual chest compressions in situations where sustained high-quality manual chest compressions are impractical or compromise provider safety (good practice statement).

  • Administration of Buffering Agents During Cardiac Arrest – Suggest against the administration of buffering agents such as sodium bicarbonate in the treatment of out-of-hospital cardiac arrest, unless a special circumstance for its use is present (weak recommendation, low-certainty evidence).

  • ALS Therapies for Opioid-Related Cardiac Arrest – During ALS for cardiac arrest due to opioid poisoning, there is insufficient evidence to recommend any additional opioid-specific therapies (e.g., naloxone) beyond standard resuscitative care. If rescuers are uncertain whether a patient with suspected opioid poisoning is actually in cardiac arrest, administration of an opioid antagonist (e.g., naloxone) is warranted (good practice statement). 

  • Pharmacological Interventions for the Treatment of Hyperkalemia – (Patients without Cardiac Arrest) For the treatment of acute hyperkalemia, suggest IV insulin in combination with glucose and/or inhaled or IV beta2-agonists (weak recommendation, low-certainty evidence).

    • (Patients with Cardiac Arrest) For the treatment of cardiac arrest suspected to be caused by acute hyperkalemia, suggest IV insulin in combination with glucose (weak recommendation, very low-certainty evidence).

PLS Evidence 2025 Updates

  • Vasopressor Use During Cardiac Arrest in Children – Suggest the use of epinephrine in pediatric out-of-hospital cardiac arrest (weak recommendation, very low-certainty evidence).

    • Task Force considers the indirect evidence from OHCA to support the administration of epinephrine in pediatric in-hospital cardiac arrest (good practice statement).

  • Pulse Check Accuracy in Pediatrics During Resuscitation – Suggest that the palpation of a pulse (or its absence) is unreliable as the sole determinant of cardiac arrest and the need for chest compressions (weak recommendation, very low certainty of evidence).

    • In unresponsive children, not breathing normally and without signs of life, lay rescuers and health care professionals should begin CPR (good practice statement).

  • ABC vs. CAB: Order of Ventilation and Compression – There is insufficient evidence to support a treatment recommendation regarding the optimal order of commencing CPR in children (ie, ventilation or compression first). Task Force considers that both an ABC (ventilation followed by compression) and a CAB (compression followed by ventilation) approach are acceptable and that both ventilation and chest compressions are important components of CPR in children (good practice statement).

  • Intra-Arrest ETCO2 – For children in cardiac arrest monitoring ETCO2 may help achieve quality CPR; however, specified values to guide intra-arrest interventions have not been well established (good practice statement).

  • Blood pressure Targets Following Return of Circulation After Pediatric Cardiac Arrest – Suggest in infants and children post return of circulation, following an in-hospital or out-of-hospital cardiac arrest, that a systolic or mean arterial pressure BP >10th percentile for age should be targeted (weak recommendation, very low-certainty evidence).

  • Paddle/Pad Size and Placement in Infants and Children – (AED Users) Follow AED specific guidance and instructions for pads placement in infants and children (good practice statement).

    • (Health Care Professionals, Trained in Manual Defibrillation) In infants and children, place pads in an anterior-posterior position (good practice statement).

  • Energy Doses for Pediatric Defibrillation During Resuscitation – In the absence of evidence to demonstrate a clear preference for any particular energy dose, we suggest the use of an initial defibrillation dose of 2 J/kg to 4 J/kg for infants or children in VF or pVT cardiac arrest (weak recommendation, very low-certainty evidence).

  • Single or Stacked Shocks for Pediatric Defibrillation – from 2005 – treatment recommendation is withdrawn due to lack of evidence. For 2025 - In infants and children with out-of-hospital cardiac arrest in VF or pVT,  suggest a single-shock strategy followed by immediate CPR (beginning with chest compression) (good practice statement).

  • Pulse Check Accuracy in Children During Resuscitation – Task Force reinforced a prior recommendation stating pulse checks are not reliable. Based on the lack of evidence supporting it, a prior recommendation to begin CPR unless a pulse is palpated within 10 seconds was withdrawn and replaced: rescuers should start CPR for any unresponsive child who is not breathing and does not have signs of life (good practice statement).

  • Bradycardia with Hemodynamic Compromise in Children – Patients with bradycardia and hemodynamic compromise not responsive to oxygenation and ventilation, consider initiating CPR (good practice statement).

    • Previous treatment recommendations withdrawn include: 1) epinephrine for infants and children with bradycardia and poor perfusion not responsive to ventilation and oxygenation, 2) atropine for bradycardia caused by increased vagal tone or anti-cholinergic drug toxicity, 3) pacing is not helpful in children with bradycardia secondary to a postarrest hypoxic/ischemic myocardial insult or respiratory failure.

  • Cardiopulmonary Resuscitation in Obese Patients – Standard CPR protocols should be used in obese patients (good practice statement).

Neonatal Evidence 2025 Updates

  • Umbilical Cord Management at Birth for Nonvigorous Term and Late Preterm Infants – (Intact Umbilical Cord Milking Compared With Early Cord Clamping) – In term and late preterm infants who remain nonvigorous despite stimulation, suggest intact cord milking in preference to early cord clamping (weak recommendation, low-certainty evidence).

    • (Intact Cord Resuscitation Compared With Early Cord Clamping or Immediate Cord Clamping) There is currently insufficient evidence to recommend either for or against intact cord resuscitation for term and late preterm infants who are nonvigorous at birth.

  • Use of a Supraglottic Airway Device During Chest Compressions – In newborn infants >34 weeks’ gestation who are receiving chest compressions despite optimized positive-pressure ventilation, if placement of a tracheal tube is not possible or is unsuccessful, ventilation via a supraglottic airway device during compressions is reasonable (good practice statement).

  • Video vs Traditional Laryngoscope – Where resources and training allow, in infants being intubated at birth or on a neonatal unit, suggest the use of video laryngoscopy in comparison to traditional laryngoscopy, especially in settings where less-experienced clinicians are intubating (conditional recommendation, moderate-certainty evidence).

  • Heart Rate for Commencing Chest Compressions – In neonates being resuscitated who have a slow heart rate even after optimizing ventilation, initiating cardiac compressions when the heart rate is <60 bpm is reasonable (good practice statement).

  • Chest Compression Location on Sternum – Neonatal chest compressions should be centered over lower third of the sternum but above xiphoid (good practice statement).

  • Sodium Bicarbonate During Neonatal Resuscitation – Although a treatment recommendation for sodium bicarbonate was included in previous consensus statements (2005-2020), it can no longer be supported. Based on current methods of evaluating the certainty of evidence, task force has concluded there is neither direct nor indirect evidence to inform a treatment recommendation.

  • Blood Volume Expansion During Neonatal Resuscitation – Early volume replacement with crystalloid or red cells is indicated for newborn infants with blood loss who are not responding to resuscitation (good practice statement).

    • There is insufficient evidence to support routine use of volume administration in newborn infants with no blood loss who are refractory to ventilation, chest compressions, and epinephrine. Because blood loss may be occult, a trial of volume administration may be considered in newborn infants who do not respond to resuscitation (good practice statement).

  • Glucose Management During or Immediately After Resuscitation – Among newborn infants receiving resuscitation, blood glucose concentration should be measured early in the post-resuscitation period and monitored with serial measurements until maintained with a normal range. Infants at greatest risk of hypo- and hyperglycemia during the post-resuscitation period include preterm infants, infants receiving chest compressions or epinephrine, and those with hypoxic ischemic encephalopathy (good practice statement).

Education, Implementation, and Teams Evidence 2025 Updates 

  • CPR Education Tailored for Specific Populations – Task force encourages resuscitation councils to develop, offer, and implement tailored BLS courses for specific populations based on their needs and specific educational approach (good practice statement).

  • Faculty Development Approaches for Resuscitation Instructors – Task force encourages resuscitation councils to implement faculty development programs for the teaching staff of their accredited resuscitation courses (good practice statement).

  • Debriefing of Clinical Resuscitation Performance – Suggest performing post-event debriefing after adult, pediatric, and neonatal cardiac arrest in all settings (weak recommendation, very low-certainty evidence).

  • System Performance Improvement – Recommend the organizations or communities that treat cardiac arrest use system-improvement strategies to improve patient outcome (strong recommendation, very low-certainty evidence).

  • Prehospital Critical Care for Out-of-Hospital Cardiac Arrest – Recommend that prehospital critical-care teams attend adults with nontraumatic, out-of-hospital cardiac arrest within EMS systems with sufficient resource infrastructure (weak recommendation, low certainty of evidence).

    • We suggest that prehospital critical-care teams attend children with out-of-hospital cardiac arrest within EMS systems with sufficient resource infrastructure (weak recommendation, very low certainty of evidence).

  • CPR Coaching During Adult and Pediatric Cardiac Arrest – Recommend considering the inclusion of a CPR Coach as a member of the resuscitation team during cardiac arrest resuscitation in settings with adequate staffing (weak recommendation, very low-certainty evidence).

  • Out-of-Hospital Cardiac Arrest Termination of Resuscitation Rules – For adult out-of-hospital cardiac arrest, we conditionally recommend that EMS systems may implement termination of resuscitation (TOR) rules to assist clinicians in deciding whether to discontinue resuscitation efforts at the scene or to transport to hospital with ongoing CPR. We suggest that TOR rules may only be implemented following local validation of the TOR rule with acceptable specificity considering local culture, values and setting (conditional recommendation, very low-certainty evidence). For pediatric out-of-hospital cardiac arrest because of insufficient evidence, suggest against the use of TOR rules to decide whether to terminate resuscitation efforts (conditional recommendation, very low-certainty evidence).

  • Willingness to Provide CPR/AED – Task force encourages resuscitation councils, communities, and EMS to provide easy access to BLS courses, raise awareness about cardiac arrest and its treatment, and utilize training, public outreach, and social media to increase laypersons’ willingness to perform CPR (good practice statement).

  • CPR Feedback Device Use in Resuscitation Training – Recommend the use of CPR feedback devices during resuscitation training for health care professionals and laypersons (strong recommendation, moderate-certainty evidence).

  • Self-Directed, Digital-Based Versus Instructor-Led Cardiopulmonary Resuscitation Education and Training in Adults and Children – Suggest the use of either instructor-led training or self-directed digital training in the acquisition of CPR or AED skills in lay adults and high-school-aged (>10 years of age) children (weak recommendation, very low-certainty evidence). Suggest self-directed digital training be used when instructor-led training is not accessible, or when quantity over quality of CPR training is needed in adults and children (weak recommendation, very low-certainty evidence). There was insufficient evidence to make a recommendation on game-in-film, virtual reality, computer programs, online tutorials or app-based training as a CPR or AED training method.

  • In Situ (Workplace-Based) Cardiopulmonary Resuscitation Training – Recommend that in situ simulation may be considered as an option for CPR training where resources are readily available (strong recommendation, very low-certainty evidence).

  • Manikin Fidelity in Resuscitation Education – Suggest the use of high-fidelity manikins when training centers or organizations have the infrastructure, trained personnel, and resources to use them (weak recommendations, very low-certainty evidence).

    • If high-fidelity manikins are not available, suggest that the use of low-fidelity manikins is acceptable for life-support training in an educational setting (weak recommendation, low-certainty evidence).

First Aid Evidence 2025 Updates

  • Manual Uterine Massage for Postpartum Hemorrhage – Suggest external uterine massage, including self-massage, in the immediate postpartum period in comparison with no intervention to prevent postpartum hemorrhage, which can lead to maternal death (weak recommendation, very low-certainty evidence).

  • Unintentional Injury From Laypersons providing Chest Compressions to Patients Who Are Not in Cardiac Arrest – Recommend that laypersons initiate CPR for presumed cardiac arrest without concerns of causing unintentional injury (strong recommendation, low-certainty evidence).

    • Recommend that other rescuers (eg, trained bystanders, health care professionals, and those with a duty to respond) initiate CPR for presumed cardiac arrest without concerns of causing unintentional injury to persons not in cardiac arrest (good practice statement).

  • Preservation of Traumatic, Completely Amputated or Avulsed Body Parts – Success in replantation is time dependent; completely amputated and avulsed external body parts such as fingers, hands, arms, and legs should be retrieved and transported as soon as possible, preferably to the same health care facility as the injured person (good practice statement).

    • Replantation outcomes may be improved by cooling without freezing the amputated or avulsed part as soon as possible and throughout transportation to a health care facility. If feasible, this can be accomplished by wrapping the part in a moist clean cloth or gauze and sealing it in a watertight bag or container prior to cooling (good practice statement).

  • Treatment of Jellyfish Stings – Recommend rinsing the area of the sting with seawater (strong recommendation, very low-certainty evidence).

    • For non-life-threatening jellyfish envenomation, we suggest the use of heated water (40-45 C [104-113 F] (immersion, irrigation or shower) or hot pack application compared with application of a cold pack, topical lidocaine, benzocaine, acetic acid, Adolph’s meat tenderizer, sting aid, or sodium bicarbonate to relieve pain from a jellyfish sting (weak recommendation, very low-certainty evidence).

    • Recommend against the use of topical 10% ammonia, isopropanol, or ethanol for the treatment of jellyfish stings (weak recommendation, low-certainty evidence).

Updated Resuscitation Council “Guidelines” 

In addition to the Consensus on the Science, each of the Resuscitation Councils go on to produce their version of guidelines. In the USA, the American Heart Association produces the CPR & ECC Guidelines. The European Resuscitation Council’s Guidelines are also currently out and available for review. Guidelines are usually similar to the ILCOR recommendations (based on the science in the CoSTR document), but occasionally they are not. When I see something show up in guidelines and I want to know what the ILCOR task force for the topic had to say, as well as what research they based their consensus on, I simply go to ILCOR’s website or the published CoSTR. Since these are "guidelines" rather than laws, it's a good opportunity to review the 2025 version and see how your Service Medical Director views each recommendation. It might not be suitable to update all of your treatment protocols to align with these new standards. 

Summary 

  • So as far as the latest round of guidelines, I say calm down and carry on!

  • Review the research and the CoSTR before discarding those expensive mechanical chest compressors your service worked so hard to obtain and implement.

  • Remember resuscitations are about returning victims of cardiac arrest to their family and to work and to a happy rest of their lifetime.

  • CPR provided properly and promptly does work as many communities continue to show every day.

  • Stay informed and be careful out there!

References

  • ILCOR CoSTR:  Bray JE, Smyth MA, Perkins GD, Cash RE, Chung SP, Considine J, Dainty KN, Dassanayake V, Debaty G, Dewan M, Dicker B, Dodge N, Folke F, Ikeyama T, Hansen CM, Johnson NJ, Lukas G, Lagina A, Masterson S, Morley PT, Morrison LJ, Nehme Z, Norii T, Raffay V, Ristagno G, Samantaray A, Semeraro F, Singh B, Smith CM, Vaillancourt C, Berg KM, Olasveengen TM ; on behalf of the Basic Life Support Task Force Collaborators. Basic life support: 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations. Circulation. 2025;152(suppl 1):S34–S71. doi: 10.1161/CIR.0000000000001364

  • AHA Guidelines: Del Rios M, Bartos JA, Panchal AR, Atkins DL, Cabanas JG, Cao D, Dainty KN, Dezfulian C, Donoghue AJ, Drennan IR, Elmer J, Hirsch KG, Idris AH, Joyner BL, Kamath-Rayne BD, Kleinman ME, Kurz MC, Lasa JJ, Lee HC, McBride ME, Raymond TT, Rittenberger, JC, Schexnayder SM, Szyld E, Topjian A, Wigginton JG, Previdi JK. Part 1: executive summary: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl):S284–S312. doi: 10.1161/CIR.0000000000001372

  • European Resuscitation Guidelines: https://www.resuscitationjournal.com/article/S0300-9572(25)00282-5/fulltext 

About the Author:

Bob Elling, MPA, Paramedic (retired) – has been a career paramedic, educator, author, and EMS advocate for 5 decades. He was a paramedic with the Town of Colonie EMS Department, Albany Times Union Center, and Whiteface Mountain Medical Services. He was also an Albany Medical Center Clinical Instructor at the HVCC Paramedic Program. Bob served as AHA National/Regional Faculty and participated in many successful life-saving legislative campaigns with the You’re the Cure Network. He also served as paramedic and lieutenant for New York City EMS, a paramedic program director, and associate director of the New York State EMS Bureau. He has authored hundreds of articles, videos, Blogs, and textbooks to prepare EMS providers for their career. Bob is the ECSI Medical Editor for the CPR and First Aid Series, Co-Author of EVOS-2, and Co-Lead Editor of Nancy Caroline’s Emergency Care in the Streets.

 

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Understanding the 2026 ILCOR Guidelines for CPR, ECC, and First Aid

by  Bob Elling     Nov 20, 2025
2026-ilcor-guidelines

This time of year often brings "guidelines fever," but it's important not to overreact. The key is to understand the process and evaluate the strength of the recommendations. 

In reviewing the ILCOR Consensus on Science with Treatment Recommendations (CoSTR) from the 10/22/25 Circulation supplement, I have found there are few changes impacting lay rescuers, first aid providers, and most prehospital EMS providers. The document contains few "strongly recommended" actions and even fewer based on "high certainty of evidence." Most are "good practice statements." Let's explore the highlights.

What is ILCOR? 

The International Liaison Committee on Resuscitation (ILCOR), established in 1992, serves as a global forum for resuscitation organizations. Comprising 10 resuscitation councils, ILCOR aims to save more lives worldwide through resuscitation. They focus on promoting, disseminating, and advocating for the international implementation of evidence-based resuscitation and first aid, using transparent evaluation and consensus on scientific data. ILCOR operates through six Task Forces. 

  • Basic Life Support (BLS)
  • Advanced Life Support (ALS)
  • Pediatric Life Support (PLS)
  • Neonatal Life Support (NLS)
  • Education, Implementation, and Teams (EIT)
  • First Aid

The CoSTR document features an Executive Summary, details on the evidence evaluation process, conflict of interest management, and chapters from each of the six Task Forces with updates from the past year. It also summarizes topics reviewed since 2020, making it a comprehensive 5-year update.

ILCOR’s Process

The guidance is supported by three approaches: systematic review (SysRev), scoping review (ScopRev), and evidence update (EvUps). The systematic review, the most detailed, starts by identifying topics and formulating questions using the PICOST framework (population, intervention, comparator, outcome, study design, and time frame). Detailed steps are in the methodology section. After thorough review, task forces reach a consensus on science to make treatment recommendations based on recommendation strength and evidence certainty. Sometimes, a good practice statement is made despite limited evidence. 

If you have time, I recommend reviewing the entire document. If not, I've highlighted the new 2025 updates for each Task Force, along with other recommendations since 2020 not listed here.

Click below to see updates for each specific Task Force:

BLS Evidence 2025 Updates

  • AED Accessibility (Locked Cabinets) – Advise against using locked cabinets for public access defibrillator storage (good practice statement).

    • If locked cabinets are used, ensure instructions for unlocking are clear and minimize access delays (good practice statement).

    • EMS should devise strategies to return public access defibrillators when used (good practice statement).

  • CAB vs ABC in Drowning: CPR – Recommend a compression-first strategy (CAB) for laypeople providing resuscitation for adults in cardiac arrest caused by drowning (good practice statement).

    • Health care professionals and those trained with a duty to respond to drowning (e.g., lifeguards) should consider providing rescue breaths/ventilation first (ABC) before chest compressions (good practice statement).

  • CPR in Obese Patients – Standard CPR protocols should be used in obese patients (good practice statement). 

ALS Evidence 2025 Updates

  • Mechanical CPR Devices – Suggest against the routine use of automated mechanical chest compression devices to replace manual chest compressions for out-of-hospital cardiac arrest (weak recommendation, low-certainty evidence).

  • Automated mechanical chest compression devices may be a reasonable alternative to manual chest compressions in situations where sustained high-quality manual chest compressions are impractical or compromise provider safety (good practice statement).

  • Administration of Buffering Agents During Cardiac Arrest – Suggest against the administration of buffering agents such as sodium bicarbonate in the treatment of out-of-hospital cardiac arrest, unless a special circumstance for its use is present (weak recommendation, low-certainty evidence).

  • ALS Therapies for Opioid-Related Cardiac Arrest – During ALS for cardiac arrest due to opioid poisoning, there is insufficient evidence to recommend any additional opioid-specific therapies (e.g., naloxone) beyond standard resuscitative care. If rescuers are uncertain whether a patient with suspected opioid poisoning is actually in cardiac arrest, administration of an opioid antagonist (e.g., naloxone) is warranted (good practice statement). 

  • Pharmacological Interventions for the Treatment of Hyperkalemia – (Patients without Cardiac Arrest) For the treatment of acute hyperkalemia, suggest IV insulin in combination with glucose and/or inhaled or IV beta2-agonists (weak recommendation, low-certainty evidence).

    • (Patients with Cardiac Arrest) For the treatment of cardiac arrest suspected to be caused by acute hyperkalemia, suggest IV insulin in combination with glucose (weak recommendation, very low-certainty evidence).

PLS Evidence 2025 Updates

  • Vasopressor Use During Cardiac Arrest in Children – Suggest the use of epinephrine in pediatric out-of-hospital cardiac arrest (weak recommendation, very low-certainty evidence).

    • Task Force considers the indirect evidence from OHCA to support the administration of epinephrine in pediatric in-hospital cardiac arrest (good practice statement).

  • Pulse Check Accuracy in Pediatrics During Resuscitation – Suggest that the palpation of a pulse (or its absence) is unreliable as the sole determinant of cardiac arrest and the need for chest compressions (weak recommendation, very low certainty of evidence).

    • In unresponsive children, not breathing normally and without signs of life, lay rescuers and health care professionals should begin CPR (good practice statement).

  • ABC vs. CAB: Order of Ventilation and Compression – There is insufficient evidence to support a treatment recommendation regarding the optimal order of commencing CPR in children (ie, ventilation or compression first). Task Force considers that both an ABC (ventilation followed by compression) and a CAB (compression followed by ventilation) approach are acceptable and that both ventilation and chest compressions are important components of CPR in children (good practice statement).

  • Intra-Arrest ETCO2 – For children in cardiac arrest monitoring ETCO2 may help achieve quality CPR; however, specified values to guide intra-arrest interventions have not been well established (good practice statement).

  • Blood pressure Targets Following Return of Circulation After Pediatric Cardiac Arrest – Suggest in infants and children post return of circulation, following an in-hospital or out-of-hospital cardiac arrest, that a systolic or mean arterial pressure BP >10th percentile for age should be targeted (weak recommendation, very low-certainty evidence).

  • Paddle/Pad Size and Placement in Infants and Children – (AED Users) Follow AED specific guidance and instructions for pads placement in infants and children (good practice statement).

    • (Health Care Professionals, Trained in Manual Defibrillation) In infants and children, place pads in an anterior-posterior position (good practice statement).

  • Energy Doses for Pediatric Defibrillation During Resuscitation – In the absence of evidence to demonstrate a clear preference for any particular energy dose, we suggest the use of an initial defibrillation dose of 2 J/kg to 4 J/kg for infants or children in VF or pVT cardiac arrest (weak recommendation, very low-certainty evidence).

  • Single or Stacked Shocks for Pediatric Defibrillation – from 2005 – treatment recommendation is withdrawn due to lack of evidence. For 2025 - In infants and children with out-of-hospital cardiac arrest in VF or pVT,  suggest a single-shock strategy followed by immediate CPR (beginning with chest compression) (good practice statement).

  • Pulse Check Accuracy in Children During Resuscitation – Task Force reinforced a prior recommendation stating pulse checks are not reliable. Based on the lack of evidence supporting it, a prior recommendation to begin CPR unless a pulse is palpated within 10 seconds was withdrawn and replaced: rescuers should start CPR for any unresponsive child who is not breathing and does not have signs of life (good practice statement).

  • Bradycardia with Hemodynamic Compromise in Children – Patients with bradycardia and hemodynamic compromise not responsive to oxygenation and ventilation, consider initiating CPR (good practice statement).

    • Previous treatment recommendations withdrawn include: 1) epinephrine for infants and children with bradycardia and poor perfusion not responsive to ventilation and oxygenation, 2) atropine for bradycardia caused by increased vagal tone or anti-cholinergic drug toxicity, 3) pacing is not helpful in children with bradycardia secondary to a postarrest hypoxic/ischemic myocardial insult or respiratory failure.

  • Cardiopulmonary Resuscitation in Obese Patients – Standard CPR protocols should be used in obese patients (good practice statement).

Neonatal Evidence 2025 Updates

  • Umbilical Cord Management at Birth for Nonvigorous Term and Late Preterm Infants – (Intact Umbilical Cord Milking Compared With Early Cord Clamping) – In term and late preterm infants who remain nonvigorous despite stimulation, suggest intact cord milking in preference to early cord clamping (weak recommendation, low-certainty evidence).

    • (Intact Cord Resuscitation Compared With Early Cord Clamping or Immediate Cord Clamping) There is currently insufficient evidence to recommend either for or against intact cord resuscitation for term and late preterm infants who are nonvigorous at birth.

  • Use of a Supraglottic Airway Device During Chest Compressions – In newborn infants >34 weeks’ gestation who are receiving chest compressions despite optimized positive-pressure ventilation, if placement of a tracheal tube is not possible or is unsuccessful, ventilation via a supraglottic airway device during compressions is reasonable (good practice statement).

  • Video vs Traditional Laryngoscope – Where resources and training allow, in infants being intubated at birth or on a neonatal unit, suggest the use of video laryngoscopy in comparison to traditional laryngoscopy, especially in settings where less-experienced clinicians are intubating (conditional recommendation, moderate-certainty evidence).

  • Heart Rate for Commencing Chest Compressions – In neonates being resuscitated who have a slow heart rate even after optimizing ventilation, initiating cardiac compressions when the heart rate is <60 bpm is reasonable (good practice statement).

  • Chest Compression Location on Sternum – Neonatal chest compressions should be centered over lower third of the sternum but above xiphoid (good practice statement).

  • Sodium Bicarbonate During Neonatal Resuscitation – Although a treatment recommendation for sodium bicarbonate was included in previous consensus statements (2005-2020), it can no longer be supported. Based on current methods of evaluating the certainty of evidence, task force has concluded there is neither direct nor indirect evidence to inform a treatment recommendation.

  • Blood Volume Expansion During Neonatal Resuscitation – Early volume replacement with crystalloid or red cells is indicated for newborn infants with blood loss who are not responding to resuscitation (good practice statement).

    • There is insufficient evidence to support routine use of volume administration in newborn infants with no blood loss who are refractory to ventilation, chest compressions, and epinephrine. Because blood loss may be occult, a trial of volume administration may be considered in newborn infants who do not respond to resuscitation (good practice statement).

  • Glucose Management During or Immediately After Resuscitation – Among newborn infants receiving resuscitation, blood glucose concentration should be measured early in the post-resuscitation period and monitored with serial measurements until maintained with a normal range. Infants at greatest risk of hypo- and hyperglycemia during the post-resuscitation period include preterm infants, infants receiving chest compressions or epinephrine, and those with hypoxic ischemic encephalopathy (good practice statement).

Education, Implementation, and Teams Evidence 2025 Updates 

  • CPR Education Tailored for Specific Populations – Task force encourages resuscitation councils to develop, offer, and implement tailored BLS courses for specific populations based on their needs and specific educational approach (good practice statement).

  • Faculty Development Approaches for Resuscitation Instructors – Task force encourages resuscitation councils to implement faculty development programs for the teaching staff of their accredited resuscitation courses (good practice statement).

  • Debriefing of Clinical Resuscitation Performance – Suggest performing post-event debriefing after adult, pediatric, and neonatal cardiac arrest in all settings (weak recommendation, very low-certainty evidence).

  • System Performance Improvement – Recommend the organizations or communities that treat cardiac arrest use system-improvement strategies to improve patient outcome (strong recommendation, very low-certainty evidence).

  • Prehospital Critical Care for Out-of-Hospital Cardiac Arrest – Recommend that prehospital critical-care teams attend adults with nontraumatic, out-of-hospital cardiac arrest within EMS systems with sufficient resource infrastructure (weak recommendation, low certainty of evidence).

    • We suggest that prehospital critical-care teams attend children with out-of-hospital cardiac arrest within EMS systems with sufficient resource infrastructure (weak recommendation, very low certainty of evidence).

  • CPR Coaching During Adult and Pediatric Cardiac Arrest – Recommend considering the inclusion of a CPR Coach as a member of the resuscitation team during cardiac arrest resuscitation in settings with adequate staffing (weak recommendation, very low-certainty evidence).

  • Out-of-Hospital Cardiac Arrest Termination of Resuscitation Rules – For adult out-of-hospital cardiac arrest, we conditionally recommend that EMS systems may implement termination of resuscitation (TOR) rules to assist clinicians in deciding whether to discontinue resuscitation efforts at the scene or to transport to hospital with ongoing CPR. We suggest that TOR rules may only be implemented following local validation of the TOR rule with acceptable specificity considering local culture, values and setting (conditional recommendation, very low-certainty evidence). For pediatric out-of-hospital cardiac arrest because of insufficient evidence, suggest against the use of TOR rules to decide whether to terminate resuscitation efforts (conditional recommendation, very low-certainty evidence).

  • Willingness to Provide CPR/AED – Task force encourages resuscitation councils, communities, and EMS to provide easy access to BLS courses, raise awareness about cardiac arrest and its treatment, and utilize training, public outreach, and social media to increase laypersons’ willingness to perform CPR (good practice statement).

  • CPR Feedback Device Use in Resuscitation Training – Recommend the use of CPR feedback devices during resuscitation training for health care professionals and laypersons (strong recommendation, moderate-certainty evidence).

  • Self-Directed, Digital-Based Versus Instructor-Led Cardiopulmonary Resuscitation Education and Training in Adults and Children – Suggest the use of either instructor-led training or self-directed digital training in the acquisition of CPR or AED skills in lay adults and high-school-aged (>10 years of age) children (weak recommendation, very low-certainty evidence). Suggest self-directed digital training be used when instructor-led training is not accessible, or when quantity over quality of CPR training is needed in adults and children (weak recommendation, very low-certainty evidence). There was insufficient evidence to make a recommendation on game-in-film, virtual reality, computer programs, online tutorials or app-based training as a CPR or AED training method.

  • In Situ (Workplace-Based) Cardiopulmonary Resuscitation Training – Recommend that in situ simulation may be considered as an option for CPR training where resources are readily available (strong recommendation, very low-certainty evidence).

  • Manikin Fidelity in Resuscitation Education – Suggest the use of high-fidelity manikins when training centers or organizations have the infrastructure, trained personnel, and resources to use them (weak recommendations, very low-certainty evidence).

    • If high-fidelity manikins are not available, suggest that the use of low-fidelity manikins is acceptable for life-support training in an educational setting (weak recommendation, low-certainty evidence).

First Aid Evidence 2025 Updates

  • Manual Uterine Massage for Postpartum Hemorrhage – Suggest external uterine massage, including self-massage, in the immediate postpartum period in comparison with no intervention to prevent postpartum hemorrhage, which can lead to maternal death (weak recommendation, very low-certainty evidence).

  • Unintentional Injury From Laypersons providing Chest Compressions to Patients Who Are Not in Cardiac Arrest – Recommend that laypersons initiate CPR for presumed cardiac arrest without concerns of causing unintentional injury (strong recommendation, low-certainty evidence).

    • Recommend that other rescuers (eg, trained bystanders, health care professionals, and those with a duty to respond) initiate CPR for presumed cardiac arrest without concerns of causing unintentional injury to persons not in cardiac arrest (good practice statement).

  • Preservation of Traumatic, Completely Amputated or Avulsed Body Parts – Success in replantation is time dependent; completely amputated and avulsed external body parts such as fingers, hands, arms, and legs should be retrieved and transported as soon as possible, preferably to the same health care facility as the injured person (good practice statement).

    • Replantation outcomes may be improved by cooling without freezing the amputated or avulsed part as soon as possible and throughout transportation to a health care facility. If feasible, this can be accomplished by wrapping the part in a moist clean cloth or gauze and sealing it in a watertight bag or container prior to cooling (good practice statement).

  • Treatment of Jellyfish Stings – Recommend rinsing the area of the sting with seawater (strong recommendation, very low-certainty evidence).

    • For non-life-threatening jellyfish envenomation, we suggest the use of heated water (40-45 C [104-113 F] (immersion, irrigation or shower) or hot pack application compared with application of a cold pack, topical lidocaine, benzocaine, acetic acid, Adolph’s meat tenderizer, sting aid, or sodium bicarbonate to relieve pain from a jellyfish sting (weak recommendation, very low-certainty evidence).

    • Recommend against the use of topical 10% ammonia, isopropanol, or ethanol for the treatment of jellyfish stings (weak recommendation, low-certainty evidence).

Updated Resuscitation Council “Guidelines” 

In addition to the Consensus on the Science, each of the Resuscitation Councils go on to produce their version of guidelines. In the USA, the American Heart Association produces the CPR & ECC Guidelines. The European Resuscitation Council’s Guidelines are also currently out and available for review. Guidelines are usually similar to the ILCOR recommendations (based on the science in the CoSTR document), but occasionally they are not. When I see something show up in guidelines and I want to know what the ILCOR task force for the topic had to say, as well as what research they based their consensus on, I simply go to ILCOR’s website or the published CoSTR. Since these are "guidelines" rather than laws, it's a good opportunity to review the 2025 version and see how your Service Medical Director views each recommendation. It might not be suitable to update all of your treatment protocols to align with these new standards. 

Summary 

  • So as far as the latest round of guidelines, I say calm down and carry on!

  • Review the research and the CoSTR before discarding those expensive mechanical chest compressors your service worked so hard to obtain and implement.

  • Remember resuscitations are about returning victims of cardiac arrest to their family and to work and to a happy rest of their lifetime.

  • CPR provided properly and promptly does work as many communities continue to show every day.

  • Stay informed and be careful out there!

References

  • ILCOR CoSTR:  Bray JE, Smyth MA, Perkins GD, Cash RE, Chung SP, Considine J, Dainty KN, Dassanayake V, Debaty G, Dewan M, Dicker B, Dodge N, Folke F, Ikeyama T, Hansen CM, Johnson NJ, Lukas G, Lagina A, Masterson S, Morley PT, Morrison LJ, Nehme Z, Norii T, Raffay V, Ristagno G, Samantaray A, Semeraro F, Singh B, Smith CM, Vaillancourt C, Berg KM, Olasveengen TM ; on behalf of the Basic Life Support Task Force Collaborators. Basic life support: 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations. Circulation. 2025;152(suppl 1):S34–S71. doi: 10.1161/CIR.0000000000001364

  • AHA Guidelines: Del Rios M, Bartos JA, Panchal AR, Atkins DL, Cabanas JG, Cao D, Dainty KN, Dezfulian C, Donoghue AJ, Drennan IR, Elmer J, Hirsch KG, Idris AH, Joyner BL, Kamath-Rayne BD, Kleinman ME, Kurz MC, Lasa JJ, Lee HC, McBride ME, Raymond TT, Rittenberger, JC, Schexnayder SM, Szyld E, Topjian A, Wigginton JG, Previdi JK. Part 1: executive summary: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl):S284–S312. doi: 10.1161/CIR.0000000000001372

  • European Resuscitation Guidelines: https://www.resuscitationjournal.com/article/S0300-9572(25)00282-5/fulltext 

About the Author:

Bob Elling, MPA, Paramedic (retired) – has been a career paramedic, educator, author, and EMS advocate for 5 decades. He was a paramedic with the Town of Colonie EMS Department, Albany Times Union Center, and Whiteface Mountain Medical Services. He was also an Albany Medical Center Clinical Instructor at the HVCC Paramedic Program. Bob served as AHA National/Regional Faculty and participated in many successful life-saving legislative campaigns with the You’re the Cure Network. He also served as paramedic and lieutenant for New York City EMS, a paramedic program director, and associate director of the New York State EMS Bureau. He has authored hundreds of articles, videos, Blogs, and textbooks to prepare EMS providers for their career. Bob is the ECSI Medical Editor for the CPR and First Aid Series, Co-Author of EVOS-2, and Co-Lead Editor of Nancy Caroline’s Emergency Care in the Streets.

 

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