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October 21, 2025 Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 S554

Wigginton et al Advanced Life Support: 2025 AHA Guidelines for CPR and ECC

management strategies. With appropriate expertise and resources, adjuncts to standard cardiac arrest resuscitation provide additional data to support and enhance care delivery. Adjuncts—such as POCUS, ETCO2 monitoring, blood gas analysis, or arterial lines—may enable the incorporation of precise physiologic parameters to optimize individual resuscitation. Head-up CPR seeks to augment conventional supine CPR to increase cerebral perfusion pressure with the goal of improving neurologically favorable outcome. Head-up CPR has been studied as a bundle of care combining mechanical chest compressions, an impedance threshold device, and application of an automated device to control sequential elevation of the head and thorax during compressions. While emerging but limited data exist for many of these CPR adjuncts, more research is needed to inform future guidelines.

Recommendation-Specific Supportive Text

1 ETCO2 values during CPR serve as a surrogate

for cardiac output.1,2 A secondary analysis of the Pragmatic Airway Resuscitation Trial found that temporal increases in ETCO2 were associated with ROSC.3 A systematic review of 8 observational studies found that an abrupt increase in ETCO2 was a predictor of ROSC; however, no absolute cutoff value was identified.4 Data suggests that a sudden increase greater than 10 mm Hg may indicate ROSC,5,6 although ROSC can still occur with ETCO2 increases of less than 10 mm Hg.7 These findings may be influenced by other factors known to impact ETCO2, including minute ventilation, CPR quality, the administration of epinephrine or sodium bicarbonate, airway management strategies, and the etiology of cardiac arrest.8,9

2 Multiple observational studies report the use of

POCUS during cardiac arrest to aid in the identification of potentially reversible causes of cardiac arrest, such as pulmonary embolism, cardiac tamponade, effusion, myocardial infarction, aortic dissection, and hypovolemia. However, evidence for diagnosing these target conditions is limited by inconsistent clinical protocols, sonographic measures, and operator experience, resulting in a high degree of heterogeneity among the studies with a high concern for bias.10 Furthermore, the use of POCUS has been associated with longer interruptions in chest compressions, longer duration of resuscitation, and higher rates of interventions.11,12 Therefore, even when a user with adequate skill and expertise uses POCUS during cardiac arrest, attention to minimizing interruptions in CPR is a priority.10,13–16 3 POCUS has been used to assess cardiac

activity and, in the absence of cardiac motion in conjunction with other modalities, to terminate resuscitative efforts.14,17–20 However, only a small number of observational studies, with significant limitations, including variability in the definitions of sonographic findings, describe its use in this setting.21–23 A single small RCT, multiple systematic reviews, and a meta-analysis of observational studies have consistently found no improvement in outcomes with the use of POCUS during cardiac arrest.23–25 Future research that standardizes image acquisition and other study methodology to examine the utility of POCUS for this indication are required. An alternative modality, transesophageal echocardiography, has the potential to provide highquality imaging of cardiac structure and function without interrupting CPR. However, the utility of transesophageal echocardiography during CPR remains a knowledge gap. 4.	 No adult human trials directly compare levels of inspired oxygen concentration during CPR. Retrospective studies have found that higher intraarrest partial pressure of oxygen in the alveoli is associated with survival to hospital admission,26 survival to hospital discharge,27 and survival with favorable neurological outcome.28 However, these findings may be influenced by patient selection, airway management strategies, and the quality of resuscitation. 5.	 Small prospective studies with significant limita-

tions have found arterial blood gas parameters, such as partial pressure of oxygen and partial pressure of carbon dioxide, to be predictive of ROSC.29,30 However, both partial pressure of oxygen and partial pressure of carbon dioxide are dependent on cardiac output and can be influenced by patient factors and the quality of CPR. Additionally, numerous retrospective studies have assessed intra-arrest blood gas analysis as a predictive tool for outcomes but suffer from similar limitations, compounded by their retrospective design.26–28,31–38

6 A retrospective study from the AHA’s Get With

the Guidelines-Resuscitation found the use of ETCO2 or diastolic blood pressure monitoring during CPR was associated with increased rate of ROSC.39 ETCO2 values reflect pulmonary circulation and cardiac output1,2 and are positively correlated with increased compression depth40– 42 and release velocity.40,41 Multiple systematic reviews have found numeric ETCO2 measures to be a predictor of ROSC.4,43 An ETCO2 less than 10 mm Hg is generally associated with poor outcomes, whereas values above 10 mm Hg, and

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