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October 21, 2025 Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 S558

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

3 The UTOR rule, which uses the same criteria as the

BLS rule (ie, arrest not witnessed by EMS professionals; no shock delivered; no ROSC), has been prospectively validated in combined BLS/ALS, or tiered response, EMS agencies.3 Although the rule did not have adequate specificity after 6 minutes of resuscitation (false-positive rate: 2.1%) it did achieve better than 99% specificity after approximately 15 minutes of attempted resuscitation while still reducing transportation by half. A retrospective analysis found that the application of the UTOR rule at 20 minutes of resuscitation was able to predict futility, identifying over 99% of survivors and patients with good neurological outcome.4 Another meta-analysis2 also examined the UTOR rule in 19 studies, many of which had initially been classified as employing the BLS TOR rule in tiered BLS + ALS EMS systems. After reclassification, the pooled specificity of the UTOR rule was reported to be 88% (95% CI, 0.88–0.94). Notably, 10 of the 11 reclassified studies were conducted outside of North America. 4.	 In intubated patients, an ETCO2 measurement of less than 10 mm Hg indicates little to no cardiac output. Several small retrospective studies provide evidence showing that an ETCO2 less than 10 mm Hg after 20 minutes of ALS resuscitation is strongly but not perfectly predictive of futility.5–8 These small observational studies suffer from a high risk of bias. Alternative ETCO2 thresholds, time points, and changes in ETCO2 over time have been proposed.9–12 The use of ETCO2 alone to predict patient outcome needs to be validated in a large prospective study.2 No data is available that addresses ETCO2 measurement with supraglottic airways and predicts poor outcomes. Additionally, isolated ETCO2 values greater than 20 mm Hg, at later stages of resuscitation, should not be used in isolation as a potential indicator for continued resuscitation, particularly when other prognostic indicators are not favorable. High-quality studies assessing the role of ETCO2 for termination of resuscitation in patients on mechanical CPR have not been conducted and are an active area of research. 5.	 No studies were found that specifically examined

the use of ETCO2 in cardiac arrest patients without an advanced airway. It is not known whether ETCO2 values during bag-mask ventilation are as reliable as those with an advanced airway in place. There is insufficient evidence to support a universal “cutoff value” of ETCO2 for decisions about TOR in a nonintubated patient.

REFERENCES

1 Ebell MH, Vellinga A, Masterson S, Yun P. Meta-analysis of the accuracy of

termination of resuscitation rules for out-of-hospital cardiac arrest. Emerg Med J. 2019;36:479–484. doi: 10.1136/emermed-2018-207833 2 Kwong JL, Drennan IR, Turner L, Cheskes S. Predefibrillation end-

tidal CO2 and defibrillation success in out-of-hospital cardiac arrest: an observational cohort study. Emerg Med J. 2023;40:48–55. doi: 10.1136/emermed-2021-211951 3.	 Grunau B, Taylor J, Scheuermeyer FX, Stenstrom R, Dick W, Kawano T, Barbic D, Drennan I, Christenson J. External Validation of the Universal Termination of Resuscitation Rule for Out-of-Hospital Cardiac Arrest in British Columbia. Ann Emerg Med. 2017;70:374–381.e1. doi: 10.1016/j.annemergmed.2017.01.030 4.	 Drennan IR, Case E, Verbeek PR, Reynolds JC, Goldberger ZD, Jasti J, Charleston M, Herren H, Idris AH, Leslie PR, et al; Resuscitation Outcomes Consortium Investigators. A comparison of the universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest. Resuscitation. 2017;111:96–102. doi: 10.1016/j.resuscitation.2016.11.021 5.	 Wayne MA, Levine RL, Miller CC. Use of end-tidal carbon dioxide to predict outcome in prehospital cardiac arrest. Ann Emerg Med. 1995;25:762–767. doi: 10.1016/s0196-0644(95)70204-0 6.	 Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med. 1997;337:301–306. doi: 10.1056/NEJM199707313370503 7.	 Akinci E, Ramadan H, Yuzbasioglu Y, Coskun F. Comparison of end-tidal carbon dioxide levels with cardiopulmonary resuscitation success presented to emergency department with cardiopulmonary arrest. Pak J Med Sci. 2014;30:16–21. doi: 10.12669/pjms.301.4024 8.	 Ahrens T, Schallom L, Bettorf K, Ellner S, Hurt G, O’Mara V, Ludwig J, George W, Marino T, Shannon W. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care. 2001;10:391–398. 9.	 Sun KF, Poon KM, Lui CT, Tsui KL. Clinical prediction rule of termination of resuscitation for out-of-hospital cardiac arrest patient with prehospital defibrillation given. Am J Emerg Med. 2021;50:733–738. doi: 10.1016/j.ajem.2021.09.058 10.	 Nassal MMJ, Elola A, Aramendi E, Jaureguibeitia X, Powell JR, Idris A, Raya Krishnamoorthy BP, Daya MR, Aufderheide TP, Carlson JN, et al. Temporal Trends in End-Tidal Capnography and Outcomes in Out-of-Hospital Cardiac Arrest: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2024;7:e2419274. doi: 10.1001/jamanetworkopen.2024.19274 11.	 Crickmer M, Drennan IR, Turner L, Cheskes S. The association between end-tidal CO2 and return of spontaneous circulation after out-of-hospital cardiac arrest with pulseless electrical activity. Resuscitation. 2021;167:76– 81. doi: 10.1016/j.resuscitation.2021.08.014 12.	 Cereceda-Sánchez FJ, Ponce-Taylor J, Montero-París P, Unzaga-Ercilla I,

Martinez-Cuellar N, Molina-Mula J. Initial capnography values and resuscitation outcomes of patients assisted by basic life support units in first instance; descriptive prospective study. Signa Vitae. 2021;17:86–91. doi: 10.22514/sv.2021.099

ADVANCED AIRWAY PLACEMENT DURING RESUSCITATION

Recommendations for Advanced Airway Placement During Resuscitation COR LOE Recommendations

1 B-NR 1.  Frequent experience or frequent retraining is recommended for health care professionals who perform endotracheal intubation in adults with cardiac arrest.

1 C-LD 2.  If advanced airway placement will interrupt chest compressions, health care professionals should defer insertion of the airway until the adult in cardiac arrest fails to respond to initial CPR and defibrillation attempts or obtains ROSC.

1 C-LD 3.  Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube in adults with cardiac arrest.

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