ERC 2025 - We continue the Analysis: What's new in the ALS field?

After exploring the new features of 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: "There goes another round of changes...".

Don't worry: as we have seen for education, here too the mantra is intelligent evolution , not revolution. But there are some surprises that are 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: less technological frills, more operational substance. A clear thread that runs through the whole new European vision.

1. VF Refractory: The Disappointment of the Century (But We Remain Optimistic)

Let's be clear: I was (and remain) a huge fan of DSD . Seeing the ERC 2025 relegate it to research protocols hurts a bit, I admit. But I understand the logic: two defibrillators are needed, it 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 hopeful. As I discussed in my article on refractory VF in cardiac arrest, what to do? Reasoning around the DOSE VF study , DSD has a solid pathophysiological logic. We just need more robust evidence, and we will probably have it in the next few years.

Meanwhile on the field: Second set of pads in each kit, fluid vector-change training, and... patience. Science has its own time.

2. Airways: Heart-Warming Pragmatism

Here instead I am definitely happy . Finally seeing in black and white that:

• Two-man BVM is the standard, not the exception. Let's learn to "Ambare" well, use quiet shifts for exercises.

• i-gel preferred to laryngeal tube.

• Intubation only for "ninjas" (>95% success in ≤2 attempts).

It is the triumph of clinical pragmatism over years of professional ego. How many times have we seen colleagues insist on difficult intubations while the patient desaturates? How many endless pauses to "fix" the tube?

ERC 2025 says one simple thing: if you are not really good, use i-gel . And that is not a criticism, it is scientific realism. The i-gel works, it is fast, it is safe. End of discussion.

The focus on mandatory capnography for confirmation and continuous monitoring completes a picture of operational common sense that we have been waiting for a long time.

3. IO vs IV: Chapter Closed (Maybe)

Interesting to see how the IO-first vs IV-first debate is finally closed. The three mega-RCTs of 2024 have spoken clearly: similar times, but marginally higher IV for ROSC.

As we discussed in our IO vs IV in cardiac arrest , the issue was never really about efficacy, but about operational practicality . Now we have a definitive answer: IV first, IO after 2 failed attempts .

Translated: keep the venous skill, but keep the IO ready as a reliable backup. Simple and pragmatic.

2021 Algorythm

4. Physiological Monitoring: Finally Clear Targets (But...)

Here we come to the real game-changer of ERC 2025: explicit physiological targets to guide CPR.

ETCO₂: The Trend is Everything

ETCO₂ ≥25 mmHg as target and above all emphasis on trend rather than spot value. This changes everything in the way of interpreting 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"

This is a conceptual revolution that will require specific training for all ALS teams.

Invasive Blood Pressure: Nice Idea, But...

Diastolic ≥30 mmHg as a target. Great on paper, but in the prehospital setting? How many of us have routine invasive arterial monitoring during CPR?

Probably only useful for very advanced ALS teams. Otherwise, let's stick with ETCO₂ as the main guide.

5. Drugs: No Revolution (Too Bad)

Here the ERC 2025 have been decidedly conservative . Adrenaline 1mg every 3-5 minutes, period. Micro-doses (50-100 μg) remain reserved for monitored hospital settings.

It's a real shame that more specific instructions on when to stop with the adrenaline were not given. How many cycles? 3? 5? 30? The variability between operators and services remains enormous, and it would have been time to provide some coordinates.

At least the emphasis on early dosing in non-shockable rhythms is a concrete step forward.

6. Mechanical Devices: Uncourageous Observations

ERC 2025 recommends mechanical devices "only if manual CPR of quality is not practicable" . Theoretically flawless, practically... naive?

All professionals know that performing serious, 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 the ultimate evil: they free up human resources , ensure consistency, allow simultaneous procedures. Yes, they do not improve outcomes, but in many scenarios they are the only realistic option to maintain decent CPR.

Thank goodness they exist , let's be honest, I personally love the convenience that the Zoll AutoPulse gives us when stopping in complex places. The guidelines could be more courageous in recognizing 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 is the end of the “POCUS solves everything” era and the beginning of an evidence-based approach to imaging during resuscitation.

In the prehospital setting, this means: If you're not a truly skilled sonographer , focus on quality compressions. The ultrasound can wait.

8. Low-Resource Contexts: Unexpected Courage

Here, ERC 2025 shows unexpected courage : explicitly addressing resource-constrained contexts, recognizing that even in rich countries resources can be limited.

Two-level approach (basic + advanced), focus on prevention and BLS, operational realism. This is the first time we have seen European guidelines so honest about real-world limitations.

Well done indeed. It was about time.

Practical Toolkit 2025: Shopping List

High Priority	Medium Priority	Nice to Have
Second set pad	POCUS training	Invasive PA Monitoring
i-gel full supply	ETCO₂ protocols trend	Mechanical device
Capnography on all monitors	Drill BVM 2 operators	DSD Research Protocols
Vector change training	Drug Update	Advanced team building

The Red Thread: From Training to Practice

If we connect this ALS update with the ERC 2025 education news, a clear red thread emerges:

• Realistic simulation in training → Realistic protocols in practice

• Focus on non-technical skills → Operational pragmatism

• Personalizing Learning → Physiologically Guided CPR

It is a coherent and modern vision that runs through the entire resuscitation chain.

Final Verdict: Intelligent Evolution

The ERC ALS 2025 are not the revolution that some hoped for, but they are the intelligent evolution that the sector deserved:

• Simplify where possible (SGA vs intubation)

• Clarifying the controversies (vector-change vs DSD)

• Introduce physiological monitoring as standard

• They maintain operational realism

Sure, there are some disappointments (bye bye DSD, hello precise indications on adrenaline), but the general picture is solid and pragmatic .

The message for prehospital teams? Same spirit, better execution. Less gadgets, more substance. And above all: do the basics right, monitor intelligently, don’t chase the latest buzz if it doesn’t add real value.

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Stay tuned for more ERC 2025 coverage.

The full ERC 2025 guidelines will be published in the coming months. This article is based on the draft for public consultation available in May 2025.