After exploring the innovations in resuscitation education in ERC 2025, it's time to get our hands dirty with the beating heart of the guidelines: Advanced Life Support. And I can already hear you murmuring: "Here we go, another round of changes...". Don't worry: as we saw with education, here too the mantra is intelligent evolution, not revolution. But there are some surprises worth analyzing with the magnifying glass of the real world. The Context: From the Classroom to the Street If in education ERC 2025 focused on immersive simulation and non-technical skills, in ALS we see the same philosophy applied to clinical practice: fewer technological frills, more operational substance. A clear common thread running through the entire new European vision. 1. Refractory VF: The Disappointment of the Century (But We Remain Optimistic) Let's be clear: I was (and remain) a die-hard fan of DSD. Seeing ERC 2025 relegate it to research protocols hurts a bit, I admit. But I understand the logic: it requires two defibrillators, creates operational confusion, and above all the evidence remains "very low certainty". The choice of vector-change as the first option is pragmatic: we all have a second set of pads, the change is relatively quick, and some observational studies have shown encouraging results. But I remain confident. As I discussed in my article on refractory VF in cardiac arrest, what do we do? Reasoning around the DOSE VF study, DSD has solid pathophysiological logic. We just need more robust evidence, and we'll probably have it in the coming years. Meanwhile in the field: Second set of pads in every kit, training for fluid vector-change, and... patience. Science has its own timeline. 2. Airway Management: Pragmatism That Warms the Heart Here instead I'm definitely happy. To finally see in black and white that: Two-operator BVM is the standard, not the exception. Let's learn to "bag" well, use quiet shifts for practice. i-gel preferred over laryngeal tube. Intubation only for "ninjas" (>95% success in ≤2 attempts). It's the triumph of clinical pragmatism over years of professional ego. How many times have we seen colleagues insist on difficult intubations while the patient desaturated? How many endless pauses to "fix" the tube? ERC 2025 says one simple thing: if you're not really good, use the i-gel. And it's not a criticism, it's scientific realism. The i-gel works, it's fast, it's safe. End of discussion. The focus on mandatory capnography for confirmation and continuous monitoring completes a picture of operational common sense we've been waiting for. 3. IO vs IV: Chapter Closed (Maybe) Interesting to see how the IO-first vs IV-first debate is definitively closed. The three mega-RCTs of 2024 spoke clearly: similar times, but IV marginally superior for ROSC. As we discussed in our IO vs IV in cardiac arrest, the question was never really about efficacy, but operational practicality. Now we have a definitive answer: IV first, IO after 2 failed attempts. Translated: maintain venous skill, but keep IO ready as a reliable backup. Simple and pragmatic. 2021 Algorithm - substantially unchanged 4. Physiological Monitoring: Finally Clear Targets (But...) Here we arrive at the real game-changer of ERC 2025: explicit physiological targets to guide CPR. ETCO₂: The Trend is Everything ETCO₂ ≥25 mmHg as a target and especially emphasis on the trend rather than the spot value. This changes everything in how we interpret capnography during resuscitation. No longer: "ETCO₂ at 15, it's low but okay" But: "ETCO₂ started at 8, now at 15 and rising steadily = excellent prognostic sign" It's a conceptual revolution that will require specific training for all ALS teams. Invasive Arterial Pressure: Good Idea, But... Diastolic ≥30 mmHg as a target. Fantastic on paper, but in prehospital care? How many of us have routine invasive arterial monitoring during CPR? Probably useful only for very advanced ALS teams. For the rest, we stick with ETCO₂ as the main guide. 5. Medications: No Revolution (Too Bad) Here ERC 2025 has been decidedly conservative. Adrenaline 1mg every 3-5 minutes, period. Micro-doses (50-100 μg) remain reserved for monitored hospital settings. Real shame not to have given more specific indications on when to stop adrenaline. How many cycles? 3? 5? 30? The variability between operators and services remains enormous, and it would have been the time to give some coordinates. At least the emphasis on early doses in non-shockable rhythms is a concrete step forward. 6. Mechanical Devices: Not Very Courageous Observations ERC 2025 recommends mechanical devices "only if quality manual CPR is not feasible". Theoretically impeccable, practically... naive? All professionals know that seriously doing high-quality manual CPR for 30-40 minutes is often physically impossible, especially in difficult contexts (narrow stairs, long transports, adverse weather conditions). Mechanical compressors are not absolute evil: they free up human resources, guarantee consistency, allow simultaneous procedures. Yes, they don't improve outcome, but in many scenarios they're the only realistic option to maintain decent CPR. Thank goodness they exist, let's say it frankly, I, personally, love the practicality that Zoll's AutoPulse gives us on arrests in complex locations. The guidelines could be braver in acknowledging this. 7. POCUS: Good, But with Judgment Finally a balanced position on ultrasound during CPR: Yes, but only experienced operators Yes, but pauses ≤10 seconds Never alone for TOR decisions It's the end of the "POCUS solve everything" era and the beginning of an evidence-based approach to imaging during resuscitation. In prehospital care it means: if you're not really an expert sonographer, focus on quality compressions. Ultrasound can wait. 8. Low-Resource Settings: Unexpected Courage Here ERC 2025 shows unexpected courage: explicitly addressing contexts with limited resources, recognizing that even in wealthy countries resources can be limited. Two-tier approach (basic + advanced), focus on prevention and BLS, operational realism. It's the first time we see European guidelines so honest about real-world limitations. Well done really. It was about time. 2025 Practical Toolkit: Shopping List
| High Priority | Medium Priority | Nice to Have |
|---|
| Second set of pads | POCUS training | Invasive BP monitoring |
| Complete i-gel stock | ETCO₂ trend protocols | Mechanical device |
| Capnography on all monitors | 2-operator BVM drills | DSD research protocols |
| Vector-change training | Medication updates | Advanced team building |
The Common Thread: From Training to Practice If we connect this ALS update with the innovations in ERC 2025 education, a clear common thread emerges: Realistic simulation in training → Realistic protocols in practice Focus on non-technical skills → Operational pragmatism Personalized learning → Physiology-guided CPR It's a coherent and modern vision that runs through the entire resuscitation chain. Final Verdict: Intelligent Evolution ERC ALS 2025 is not the revolution some hoped for, but it is the intelligent evolution the field deserved: They simplify where possible (SGA vs intubation) They clarify the controversial (vector-change vs DSD) They introduce physiological monitoring as standard They maintain operational realism Sure, there are some disappointments (bye bye DSD, hello precise indications on adrenaline), but the overall picture is solid and pragmatic. The message for prehospital teams? Same spirit, better execution. Fewer gadgets, more substance. And above all: do the basics well, monitor intelligently, don't chase the latest trend if it doesn't add real value. Keep following us for analysis of the next ERC 2025 sections. The complete ERC 2025 guidelines will be published in the coming months. This article is based on the draft for public consultation available in May 2025.
