27/10/2025
The ERC guidelines 2025
Well, the Europeans have published their 2025 resuscitation guidelines. Hopefully the Australian/NZ Resuscitation Councils will follow suit soon. These aren’t the ARC guidelines, but this may give an idea of the direction that the ARC/ANZCOR guidelines will take.
Here is a link to the full ERC guidelines:
https://www.erc.edu/science-research/guidelines/guidelines-2025/guidelines-2025-english/
Although ANZCOR interprets the ILCOR guidance in its own way, and there are some differences in the ANZCOR guidelines to the ERC guidelines, the Europeans have made a few recommendations that make some sense:
The chain of survival has been significantly updated. The graphic for CPR and defibrillation have been combined and the graphic now also includes AED. The fourth link of the chain is now Survival and recovery to restore the quality of life. The image of the brain has also been enhanced in the first and fourth link of the chain.

The guidelines include key messages to strengthen epidemiology in resuscitation including screening and counselling

Also improving systems saving lives:

The adult BLS guidelines have strengthened the “Check, Call, CPR & AED” approach. Perhaps it is time for the ARC to move away from DRSABCD to the simpler approach. The simple guidelines make perfect sense and include using a mobile phone on speaker when available.

The key messages for BLS strengthen BLS Principles

The Danger part of the ERC algorithm appears to have been deemphasised. A simple linear BLS algorithm mirrors the approach for in and out of hospital response. Interestingly, BLS training includes rescue breaths and chest compression CPR is only for the non-trained provider. The ERC continues to recommend 5 rescue breaths for paediatrics for both trained and non-trained providers.

The guidelines emphasise the use of AED’s for both in and out of hospital cardiac arrest. They recommend that AED’s are placed in clear sight, in unlocked cabinets and are readily available for public use. No guidance is given on alarming cabinets, just that they should be registered with local emergency services.
Adult ALS
The ERC have included changing the defibrillator pad position to AP if three shocks are ineffective. The ERC continue to give adrenaline after three shocks and amiodarone after three shocks. They have also included some guidance for the rare occurrence of CPR induced consciousness.
Following on from the emphasis on AED use, they also recommend that ALS providers should be proficient in the use of AED’s and use the AED initiallly in ALS if it has already been deployed. A change to manual defibrillation can then occur in the 2 minute cycle.
The ERC ALS algorithm now emphasises optimising high quality CPR and ventilation on one side of the algorithm, and the identification and treatment of reversible causes on the other. There are an additional two boxes including the considerations and the immediate post resuscitation care. I like this approach, as I always think of the algorithm as having three domains, Airway oxygenation and ventilation, IV access drugs and fluids and diagnosis - potentially reversible causes. THE ERC algorithm doesn’t include CXR in the immediate post resuscitation care

There is a statement in the guideline stating that fluids should only be given during CPR if the cardiac arrest is caused be hypovolaemia. I will have to look into the source of this guidance, as I always believed in the benefit of fluid on cardiac pre-load.
The advice on mechanical chest compression devices has been altered slightly to recommend that they should be used only when high-quality CPR is not practical, or where transport during CPR is required.
The special circumstances recommendations seem to be a mixture of treatment recommendations and cardiac arrest recommendations. Some treatment recommendations differ from the current Australian guidance, for example, 20mmol KCL by slow injection rather than 5mmol push for hypokalaemia, and the use of sodium zirconium cyclosilicate for hyperkalaemia.
Although the ERC ALS algorithm concentrates on the 4H 4T approach, the guideline emphasises special settings and environmental considerations including trauma, Cath lab, perioperative, sports, in-flight and even cruise ship!
Paediatric Guidelines
The ERC continue to recommend actions that are no longer recommended by the ARC, such as abdominal thrusts. I haven’t found any major changes to the recommendations, just a different emphasis. The ERC Paediatric ALS algorithm looks similar to the ERC adult ALS algorithm, but actually reads quite differently. There is a different exit for ROSC, it isn’t particularly linear, and out of the four boxes at the bottom of the algorithm, two are similar, but in different positions, and two are different. Elements of actions are in different boxes to the adult algorithm, and I think there has been a missed opportunity to collaborate and design algorithms that support the teaching of resuscitation. Where the wording has changed on the adult algorithm, the paediatric one hasn’t been updated.

