Adult ALS Cardiac Arrest Algorithm
The 2025 American Heart Association Adult Advanced Life Support pathways — the shockable and non-shockable cardiac-arrest trees, reversible causes, and post–cardiac arrest care — with the points where subcostal-only EASy-ALS ultrasound informs the resuscitation.
New in 2025: POCUS is written into the algorithm
The 2025 Guidelines state it may be reasonable to perform echocardiography or point-of-care cardiac ultrasound in adults after ROSC to identify clinically significant diagnoses requiring intervention, and the Adult Post–Cardiac Arrest Care Algorithm now lists POCUS among early diagnostic testing. EASy-ALS is the bedside method for exactly this — a single subcostal window read inside the ≤10-second pulse/rhythm check and repeated after ROSC. Ultrasound findings must be one data point within the whole clinical picture and must never be the sole reason to stop resuscitation.
Adult cardiac arrest
High-quality CPR and early defibrillation are the cornerstones. Everything else supports them.
Start CPR · attach monitor/defibrillator
- Push hard (≥2 in / 5 cm) and fast (100–120/min); full recoil, minimize interruptions
- Give oxygen; 30:2 until an advanced airway, then continuous compressions with ventilation
- IV access first (IO if IV not feasible)
Rhythm / pulse check — ≤10 seconds
- ▶ EASy-ALS: record the subcostal 4-chamber view during the pause; interpret after compressions resume
- A nurse counts the pause down and stops the probe at 10 seconds
Shockable · VF / pulseless VT
EASy-ALS is deferred — the shock owns the pause.
Defibrillate
- Resume CPR immediately for 2 minutes
CPR 2 min · epinephrine 1 mg after shocks fail
- Then epinephrine 1 mg every 3–5 min
- Treat reversible causes (Hs & Ts)
Antiarrhythmic + shock
- Amiodarone 300 mg (then 150 mg), or lidocaine
- CPR 2 min between rhythm checks
2025: escalate defibrillation
- Vector change, or double sequential external defibrillation (DSED)
- Consider ECPR in selected patients
Non-shockable · asystole / PEA
Where EASy-ALS earns its keep — motion vs standstill and the cause.
Epinephrine 1 mg as soon as feasible
- Repeat every 3–5 min
- Resume CPR 2 min
EASy-ALS during the pause
- Cardiac motion → pseudo-PEA: hunt the reversible cause
- No motion → true PEA / standstill: poor prognosis, but not a stop order on its own
- Fibrillating myocardium → treat as fine VF and defibrillate
Treat the identified cause
- Match the pseudo-PEA pattern to its intervention (below)
- Reassess motion and rhythm at each check
ROSC → post–cardiac arrest care
- Confirm on pulse, arterial line, and EtCO₂ rise
Reversible causes — the Hs & Ts
Tinted rows are directly identifiable on EASy-ALS imaging — heart during the pause; IVC, lung, pleural, and abdominal views during compressions. The rest are excluded clinically, which is why confidently ruling out cardiac causes redirects the resuscitation.
The 5 Hs
Underfilled heart · flat IVC
The 5 Ts
Pericardial effusion
Absent sliding + lung point
Dilated right heart ± DVT
Dilated LV · RWMA post-ROSC
| EASy-ALS pattern | Suggests | Immediate action |
|---|---|---|
| Pericardial effusion | Tamponade | Pericardiocentesis |
| Dilated right heart | Massive PE (or acute-on-chronic cor pulmonale) | Reperfusion — thrombolysis; support RV |
| Dilated left heart | Massive MI | Emergent coronary angiography |
| Underfilled heart · flat IVC | Hypovolemia / hemorrhage | Volume, blood, source control |
| Absent sliding + lung point | Tension pneumothorax | Needle decompression → thoracostomy |
| Large pleural effusion | Tamponade physiology | Tube thoracostomy |
| No cardiac cause seen | Noncardiac Hs & Ts | Work hypoxia, K⁺, acidosis, toxins, temp |
Post–cardiac arrest care
After ROSC — stabilize, find the cause, protect the brain.
ROSC obtained
Airway, oxygenation & ventilation
- Confirm/exchange advanced airway with waveform capnography
- SpO₂ 90–98% (PaO₂ 60–105 mm Hg); PaCO₂ 35–45 mm Hg
Hemodynamics
- Target MAP ≥ 65 mm Hg; treat hypotension with fluids/vasopressors by phenotype
Early diagnostics
- 12-lead ECG
- ▶ POCUS / echocardiography and CT (head-to-pelvis) to find the etiology — 2025 additions
Treat etiology & complications
- Emergent coronary angiography for STEMI, shock, refractory arrhythmia, or severe ischemia
- Temporary mechanical circulatory support in selected refractory cardiogenic shock
Deliberate temperature control (goal 32–37.5 °C, ≥36 h) · EEG · multimodal neuroprognostication ≥72 h
- Avoid hypoglycemia (<70) and hyperglycemia (>180 mg/dL); consider antibiotics
What changed for adult ALS in 2025
The recommendations most likely to change practice, from the 2025 Highlights.
POCUS / echo after ROSC
2025 NewIt may be reasonable to perform echocardiography or point-of-care cardiac ultrasound in adults after ROSC to identify clinically significant diagnoses requiring intervention — the recommendation EASy-ALS operationalizes at the bedside.
Vector change & double sequential defibrillation
2025 NewFor persisting VF/pulseless VT after 3 or more consecutive shocks, recommendations for vector-change defibrillation were added and double sequential external defibrillation (DSED) was updated, on the basis of new literature.
IV access before IO
2025 UpdatedHealth care professionals should first attempt IV access for drug administration in adults; IO access is reasonable if IV attempts are unsuccessful or not feasible.
Epinephrine timing in shockable rhythms
2025 UpdatedFor a shockable rhythm, it is reasonable to give epinephrine after initial defibrillation attempts have failed — prioritizing early CPR and defibrillation.
Vasopressin adds nothing over epinephrine
2025 UpdatedVasopressin alone, or vasopressin combined with epinephrine, offers no advantage as a substitute for epinephrine in adult cardiac arrest.
Head-up CPR not recommended
2025 NewHead-up CPR in adults is not recommended outside the setting of clinical trials.
Bradycardia — transvenous pacing
2025 NewIn persistent, hemodynamically unstable bradycardia refractory to medical therapy, temporary transvenous pacing is reasonable to increase heart rate and improve symptoms.
Head-to-pelvis CT after ROSC
2025 NewIt may be reasonable to obtain head-to-pelvis CT in adults after ROSC to investigate the etiology of arrest and complications from resuscitation.
Blood pressure & temperature after arrest
2025 UpdatedAvoid hypotension by maintaining a MAP of at least 65 mm Hg; maintain temperature control for at least 36 hours in patients who remain unresponsive to verbal commands after ROSC.
Educational summary only — not a substitute for clinical judgment, formal ACLS training, or the full guideline text. Class-of-recommendation and level-of-evidence details are in the source documents. The schematics are original teaching aids, not reproductions of the AHA's copyrighted algorithm figures.
Sources
- • Del Rios M, Bartos JA, Panchal AR, et al. Part 1: Executive Summary: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl 2).
- • Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for CPR and ECC. Circulation. 2025;152(suppl 2).
- AHA 2025 Guidelines Highlights & full text (eccguidelines.heart.org)
- • Bughrara N, et al. Focused Cardiac Ultrasound and the Periresuscitative Period (EASy-ALS). A&A Practice. 2020;14(10):e01278. · Bughrara NF, et al. PeRLS for procedural sedation, enhanced by EASy-ALS. Best Pract Res Clin Anaesthesiol. 2025;39:255–266.