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Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 October 21, 2025 S547 Wigginton et al Advanced Life Support: 2025 AHA Guidelines for CPR and ECC Other pseudo-electrical therapies, such as cough CPR, fist or percussion pacing, and precordial thump have all been described as temporizing measures in select patients who are either peri-arrest or in the initial seconds of witnessed cardiac arrest (before losing consciousness in the case of cough CPR) when definitive therapy is not readily available.1 These therapies are described elsewhere (see Part 10. Special Circumstances2 for more on precordial thump, fist pacing, and cough CPR). Recommendation-Specific Supportive Text 1 Existing evidence, including observational and quasi–randomized controlled trial (RCT) data, suggests that pacing by a transcutaneous, transvenous, or transmyocardial approach during cardiac arrest does not improve the likelihood of ROSC or survival, regardless of the timing of pacing administration in established asystole, location of arrest (in-hospital or out-of-hospital), or primary cardiac rhythm (asystole, pulseless electrical activity).3–7 Protracted interruptions in chest compressions while the success of pacing is assessed can be detrimental to survival. Specifically, attempts at electrical pacing may delay evidence-based resuscitative measures, such as CPR. It is not known whether the timing of pacing initiation may influence pacing success such that pacing may be useful in the initial minute of select cases of witnessed, monitored cardiac arrest (see Part 10. Special Circumstances, Cardiac Arrest After Cardiac Surgery2). If pacing is attempted during cardiac arrest related to the special circumstances described above, professionals are cautioned that its performance could be at the expense of highquality CPR. Of note, this recommendation addressing electrical pacing is specifically focused upon patients in cardiac arrest and does not address prevention of cardiac arrest nor does it address the utility of overdrive pacing for arrhythmia. REFERENCES 1 Tucker KJ, Shaburihvili TS, Gedevanishvili AT. Manual external (fist) pac- ing during high-degree atrioventricular block: a lifesaving intervention. Am J Emerg Med. 1995;13:53–54. doi: 10.1016/0735-6757(95)90243-0 2. Cao D, Arens AM, Chow SL, Easter SR, Hoffman RS, Lagina AT, Lavonas EJ, Patil KD, Sutherland LD, Tijssen JA, et al. Part 10: adult and pediatric special circumstances of resuscitation: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl 2):S578–S672. doi: 10.1161/CIR.0000000000001378 3. White JD, Brown CG. Immediate transthoracic pacing for cardiac asystole in an emergency department setting. Am J Emerg Med. 1985;3:125–128. doi: 10.1016/0735-6757(85)90034-8 4. Sherbino J, Verbeek PR, MacDonald RD, Sawadsky BV, McDonald AC, Morrison LJ. Prehospital transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: a systematic review. Resuscitation. 2006;70:193–200. doi: 10.1016/j.resuscitation.2005.11.019 5. Hedges JR, Syverud SA, Dalsey WC, Feero S, Easter R, Shultz B. Pre- hospital trial of emergency transcutaneous cardiac pacing. Circulation. 1987;76:1337–1343. doi: 10.1161/01.cir.76.6.1337 6. Cummins RO, Graves JR, Larsen MP, Hallstrom AP, Hearne TR, Ciliberti J, Nicola RM, Horan S. Out-of-hospital transcutaneous pacing by emergency medical technicians in patients with asystolic cardiac arrest. N Engl J Med. 1993;328:1377–1382. doi: 10.1056/NEJM199305133281903 7. Barthell E, Troiano P, Olson D, Stueven HA, Hendley G. Prehospital exter- nal cardiac pacing: a prospective, controlled clinical trial. Ann Emerg Med. 1988;17:1221–1226. doi: 10.1016/s0196-0644(88)80074-x VASCULAR ACCESS IN CARDIAC ARREST MANAGEMENT Recommendations for Vascular Access in Cardiac Arrest Management COR LOE Recommendations 1 A 1. It is recommended that professionals first attempt establishing intravenous access for drug administration in adult patients in cardiac arrest. 2a A 2. Intraosseous access is reasonable if initial attempts at intravenous access are unsuccessful or not feasible for adult patients in cardiac arrest. 2b C-LD 3. For appropriately trained professionals, central venous access may be considered for adult patients in cardiac arrest if attempts to establish intravenous and intraosseous access are unsuccessful or not feasible. Synopsis Traditionally, peripheral IV access has been used to administer medication during cardiac arrest. However, obtaining IV access under emergent conditions can be challenging because of patient characteristics and operator experience leading to delay in pharmacological treatments. Alternatives to IV access for drug administration include IO, central venous, intracardiac, and endotracheal routes. Intracardiac drug administration was discouraged in the “2000 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” due to its specialized skill set requirements, potential for morbidity, and the availability of other access options.1 Similarly, drug administration via secured endotracheal tube results in low blood concentrations and unpredictable pharmacological effects and has also been removed from the guidelines.2 Central venous access is primarily used in a hospital setting because it requires specialized training to acquire and maintain proficiency. Recommendation-Specific Supportive Text 1 and 2. The peripheral IV route for vascular access has traditionally been preferred for emergency drug and fluid administration during adult resuscitation. The pharmacokinetic properties, acute effects, and clinical efficacy of emergency drugs have primarily been described for IV administration.3–6 However, observational studies have noted a significant increase in the use of IO access in adult OHCA, despite the absence of high-quality evidence.7,8 Three recent large RCTs evaluated the clinical effectiveness of initial IO access compared with Downloaded from http://ahajournals.org by on October 7, 2026