EMS News - AHA 2025 Guideline Updates

The American Heart Association (AHA) has released its 2025 updates to the Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) guidelines, introducing several important changes for both healthcare professionals and everyday responders. 

These evidence-based guidelines outline best practices that improve survival from cardiac arrest and other life-threatening cardiovascular emergencies.

A Quick Note for EMS Providers

These updates aim to streamline care, reduce variability in the field, and improve the chain of survival across diverse patient populations. 

Many of the changes emphasize consistency, simplified decision-making, and the continued integration of lay rescuers into time-critical care. 

At the same time, these updates are written to be accessible to the general public, who play a vital role in early recognition and CPR.

The 2025 release builds on the 2020 guidelines, refining previous recommendations and adding new guidance in areas that had not been previously addressed. 

Image from Circulation - AHA / ASA Journals

Below is a summary of several take-home messages and key updates that EMS Providers - and the public - should be aware of:

• Unified Chain of Survival: A single model now applies to all cardiac arrests, regardless of patient age or location, providing a consistent framework for recognizing emergencies and delivering timely interventions.

• Systems of Care: Greater focus on community preparedness, telecommunicator CPR (e.g., 911 Dispatchers), early warning systems, and health equity. 

• Remain in Place: It is recommended that resuscitation should be conducted where the patient is found, as long as high-quality cardiopulmonary resuscitation (CPR) can be administered safely and effectively.

• Position and Location of CPR: Quality chest compressions are improved by optimizing the rescuer’s hand placement, body mechanics (i.e., posture), and the patient’s position. When possible, CPR should be performed on a firm surface to maximize compression effectiveness. 

• Bariatric Patients: CPR for adult cardiac arrest patients with obesity should be provided by using the same techniques as for the average weight patient.

• Pediatric CPR: The two-thumb encircled or one-hand compression techniques are favored on the the two-finger method.

• Mechanical CPR: The routine use of mechanical CPR devices is not recommended for adults in cardiac arrest. However, mCPR may be considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous.

• Assisted Ventilations: It is still considered reasonable for both professional rescuers and lay responders to give breaths - when they are willing and able to do so with an appropriate barrier device - to improve oxygenation during cardiopulmonary resuscitation at a ratio. of 30:2 for adults.

• Choking Response: the updated sequence begins with 5 back blows, followed by 5 abdominal thrusts for all patients (e.g., adults & pediatrics), and continuing to alternate until the object is removed or the person becomes unresponsive.

• Opioid Overdose Response: The guidelines reinforce the importance of rapid naloxone administration and recommends supporting public access to opioid emergency response kits. The BLS algorithm explicitly shows where naloxone fits for suspected opioid overdose during respiratory and cardiac arrest.

Additional updates covering resuscitation education, systems of care, and post-cardiac arrest management are provided in the Highlights of the 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Image from Circulation - AHA / ASA Journals

Why These Changes Matter

Cardiac arrest remains a leading cause of sudden death. Even small improvements in CPR technique or response consistency can dramatically impact survival. The 2025 updates aim to:

• Improve clarity during high-stress emergencies
• Increase bystander willingness to act
• Standardize care across EMS, hospitals, and the community
• Enhance oxygenation and compression effectiveness
• Support faster opioid overdose interventions

For EMS providers, these recommendations reinforce strong fundamentals, situational awareness, and the life-saving importance of early naloxone access.

What You Can Do Next

Whether you are an EMS professional or a member of the public, you play a vital role in improving survival from cardiac arrest. Here are a few ways to stay prepared:

• Review the full AHA 2025 guideline highlights
• Refresh your CPR, AED, or First Aid training
• Make sure your workplace or community organization has access to naloxone and CPR equipment
• Share these updates with colleagues, friends, or family

Understanding MARCH - Preventing Hypothermia & Managing Head Injuries

From the MARCH Mnemonic Series – Tactical Trauma Care for EMS Providers

Preserve and Protect After Stabilization

The final step in the MARCH sequence - Hypothermia & Head Injury - focuses on two conditions that can rapidly worsen outcomes if not addressed early. 

After bleeding is controlled, the airway secured, respiration managed, and circulation assessed, providers must work to preserve core body temperature and protect neurological function.

Uncontrolled heat loss accelerates shock, impairs clotting, and undermines every prior intervention. Likewise, traumatic brain injury can progress quickly without vigilant monitoring and early management. 

Protecting a patient from heat loss and preserving the brain is essential for preventing secondary injury and supporting long-term survival and neurological recovery.

Image retrieved from tccc.org.ua

H – Hypothermia

Trauma-induced hypothermia is a major contributor to mortality in both military and civilian trauma.

Even in warm climates, a patient can quickly lose body heat through evaporation, convection, and exposure.

Hypothermia worsens the “lethal triad” of trauma - acidosis, coagulopathy & hypothermia - impairing clotting and promoting continued bleeding.

Image retrieved from tccc.org.ua

Recognition of Hypothermia

Look for early indicators, especially when there is significant blood loss or environmental exposure:

• Shivering or muscle tremors (may disappear as hypothermia worsens)
• Pale, cool, or mottled skin
• Slurred speech or confusion
• Slowed respirations or heart rate
• Core temperature below 95°F (35°C)

Environmental factors such as wind, wet clothing, cold ground, or prolonged evacuation time accelerate heat loss, even in mild weather.

Image retrieved from tccc.org.ua

Hypothermia Prevention and Management

• Remove wet clothing when tactically feasible and replace with dry layers.
• Insulate from the ground using a poncho, sleeping pad, or casualty blanket.
• Cover the casualty completely, including the head, to reduce radiant heat loss.
• Use hypothermia prevention kits (e.g., Blizzard Survival Blanket, Ready-Heat™ Active Warming Blanket) if available.
• Warm IV fluids or blood products when resources allow.
• Monitor core temperature if devices are available, especially in prolonged field care scenarios.

Image retrieved from tccc.org.ua

Key Point: Preventing heat loss is just as vital as stopping bleeding - once the casualty is cold, outcomes worsen rapidly.

Image retrieved from tccc.org.ua

H – Head Injury

The “H” in MARCH also stands for Head Injury, emphasizing early recognition and management of traumatic brain injury (TBI), a leading cause of preventable death and long-term disability in prehospital trauma.

Image retrieved from tccc.org.ua

Recognizing Head Trauma

Watch for the following signs and symptoms:

• Decreasing level of consciousness or responsiveness
• Unequal or dilated pupils
• Repetitive questioning, confusion, or agitation
• Persistent vomiting or seizures
• Irregular breathing patterns (Cheyne-Stokes or slow respirations)
• Obvious penetrating or blunt trauma to the skull or face

Image retrieved from tccc.org.ua

Management Principles

• Maintain airway and oxygenation. Keep SpO₂ > 90% and avoid hypoxia, which worsens secondary brain injury.
• Prevent hypotension. Maintain systolic BP ≥ 90 mmHg to ensure cerebral perfusion.
• Positioning: If spinal injury is not suspected, elevate the head 30° to promote venous drainage.
• Avoid hyperventilation unless there are signs of herniation (e.g., blown pupil, rapid deterioration).
• Control external bleeding with gentle pressure; do not compress depressed skull fractures or insert dressings into open cranial wounds.
• Monitor for changes in mental status using tools like AVPU or GCS if time and environment allow.

In the tactical environment: head injuries often coexist with blast or penetrating trauma. Managing hypoxia and hypotension early has been shown to double the odds of survival in severe TBI (Eastridge et al., 2012).

Image retrieved from tccc.org.ua

Key Takeaway for EMS and Tactical Providers

The 'H' in MARCH is about preservation and protection - maintaining the physiological stability of a casualty who has already survived the most immediate threats. 

Hypothermia prevention and head injury management require vigilance, insulation, and gentle handling. In tactical medicine, saving a life doesn’t end with hemorrhage control, it continues with keeping that life viable during evacuation.

In short: preserve the heat, protect the brain

Image retrieved from tccc.org.ua

Conclusion of the MARCH Series

The MARCH sequence - Massive Hemorrhage, Airway, Respiration, Circulation, and Hypothermia/Head Injury - originated in Tactical Combat Casualty Care and remains the foundation of modern field trauma management. 

This structured approach guides responders to address the most preventable causes of death in the order they matter most. In this series, each component of MARCH is explored in turn, offering practical guidance for EMS and tactical providers operating in dynamic, resource-limited environments. 

From controlling catastrophic bleeding to protecting core temperature and neurological function, the series outlines a clear, evidence-informed pathway for stabilizing trauma patients and improving survivability in the prehospital setting. 

Train Hard. Stay Prepared. Save Lives.

Further Reading:

American College of Surgeons Committee on Trauma. (2022) Advanced Trauma Life Support (10th Ed). Chicago, IL: American College of Surgeons.

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, MA: Pearson Education

Butler, F. K. (2017) Tactical Combat Casualty Care: Beginnings. Wilderness & Environmental Medicine 28 (2S): S12-S17. 

Retrieved from https://pubmed.ncbi.nlm.nih.gov/28284483/ on October 8, 2025

Butler, F. K., Bennett, B., & Wedmore, C. I. (2017) Tactical Combat Casualty Care and Wilderness Medicine: Advancing Trauma Care in Austere Environments. Emergency Medicine Clinics of North America 35 (2): 391-407. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28411934/ on October 8, 2025

Committee on Tactical Combat Casualty Care (2023) Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel. Defense Health Agency, Joint Trauma System. Retrieved from https://jts.health.mil on October 8. 2025

National Association of Emergency Medical Technicians NAEMT (2020) TECC: Tactical Emergency Casualty Care Course Book (2nd Ed). Burlington, MA: Jones & Bartlett Learning

National Association of Emergency Medical Technicians NAEMT (2023) Tactical Emergency Casualty Care (TECC) Guidelines. NAEMT Education Division

National Association of Emergency Medical Technicians NAEMT (2025) 

PHTLS: Prehospital Trauma Life Support, Military Edition eBook (10th Ed). Burlington, MA: Jones & Bartlett Learning

Understanding MARCH - The Role of Circulation

Image retrieved from tccc.org.ua

From the MARCH Mnemonic Series – Tactical Trauma Care for EMS Providers

After addressing massive hemorrhage, airway, and respiration, the next priority is Circulation, the body’s ability to deliver oxygenated blood to vital organs and tissues.

In trauma, the circulatory system can be compromised by shock, internal bleeding, or poor perfusion, even when obvious external hemorrhage has already been controlled.

Within the tactical environment, circulation assessment focuses on recognition and management of shock, maintaining perfusion, and preventing secondary injury. The goal is to identify subtle but deadly deterioration before it progresses beyond recovery.

C – Circulation

In tactical casualty care, circulation assessment differs slightly from the traditional EMS approach. The emphasis is on speed, simplicity, and practicality in resource-limited or high-threat conditions.

Blood pressure cuffs and monitors may not be available, so providers rely on physical signs and simple indicators to evaluate perfusion. The presence of a radial pulse and normal mental status are key field markers of adequate circulation.

Principles of Circulatory Assessment and Management

1. Check for Pulse and Perfusion

• Radial Pulse: Presence suggests systolic blood pressure above roughly 80 mmHg, generally adequate for perfusion in tactical settings.

• Weak or Absent Pulse: May indicate hypovolemia or shock; assess for additional signs of poor perfusion such as pallor, clammy skin, or delayed capillary refill.

• Mental Status: A sudden change in consciousness (e.g., confusion, lethargy) is often an early sign of inadequate cerebral perfusion.

Remember: weak radial pulse + altered mental status = shock until proven otherwise.

Image retrieved from tccc.org.ua

2. Identify and Manage Non–Life-Threatening Bleeding

Once major bleeding has been controlled, systematically check for and address secondary bleeding sites that may have been overlooked during the initial MARCH sequence. 

Apply direct pressure, pressure dressings, or hemostatic agents as needed.

Image retrieved from tccc.org.ua

3. Treat for Shock

Shock - a state of inadequate tissue perfusion - can occur from blood loss (hypovolemic), cardiac injury, or tension pneumothorax.

In tactical medicine, hemorrhagic shock is the most common.

• Lay the casualty supine, if tactical conditions allow. 

• Keep the patient warm, hypothermia worsens coagulopathy and shock (addressed further in Part Five).

• Provide fluids only when indicated by TCCC or TECC guidelines

If in shock (weak/absent radial pulse or altered mental status):

• Administer whole blood if available; otherwise, 1:1:1 blood component therapy (plasma, platelets, red cells).

• If blood products are unavailable, give Hextend or Lactated Ringer’s solution, titrating only to restore a palpable radial pulse or improved mental status (per TCCC guidance).

If the casualty is not in shock and has a palpable radial pulse and normal mental status: no IV/IO fluids are indicated.

Avoid over-resuscitation, too much fluid can dislodge clots and worsen bleeding.

4. Establish IV/IO Access When Appropriate

In tactical field care, IV or intraosseous access is indicated for:

• Fluid resuscitation in shock
• Medication administration (e.g., analgesics, antibiotics, TXA).

If available, administer Tranexamic Acid (TXA) within three hours of injury for casualties at risk of significant hemorrhage. Early TXA administration has been shown to reduce mortality from bleeding.

5. Continuous Reassessment

Circulation is dynamic, especially in prolonged field care or delayed evacuation.

• Regularly recheck:
• Pulse quality and rate
• Mental status
• Skin color, temperature, and moisture
• Wound sites for renewed bleeding

Document all findings and interventions clearly for handoff to the next echelon of care.

Image retrieved from tccc.org.ua

Key Takeaway for EMS and Tactical Providers

Circulation management is about detecting shock early, maintaining perfusion, and preventing deterioration. 

In the tactical environment, sophisticated monitoring tools are often unavailable, but trained observation remains powerful. 

The provider’s mindset should be:

Feel for the pulse, read the patient, and keep the blood where it belongs.

Image retrieved from tccc.org.ua

Coming Up Next: Part Five – Hypothermia and Head Injury

The final step in the MARCH sequence focuses on protecting what you’ve fought to preserve, preventing hypothermia and managing head injuries to maintain survivability after initial stabilization.

In Part Five, we’ll discuss how temperature control, positioning, and neurologic assessment all play critical roles in keeping your casualty alive until evacuation and definitive care.

Because in tactical medicine, saving a life isn’t just about stopping the bleeding—it’s about keeping that life sustained.

Further Reading:

American College of Surgeons Committee on Trauma. (2022) Advanced Trauma Life Support (10th Ed). Chicago, IL: American College of Surgeons.

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, MA: Pearson Education

Butler, F. K. (2017) Tactical Combat Casualty Care: Beginnings. Wilderness & Environmental Medicine 28 (2S): S12-S17. 

Retrieved from https://pubmed.ncbi.nlm.nih.gov/28284483/ on October 8, 2025

Butler, F. K., Bennett, B., & Wedmore, C. I. (2017) Tactical Combat Casualty Care and Wilderness Medicine: Advancing Trauma Care in Austere Environments. Emergency Medicine Clinics of North America 35 (2): 391-407. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28411934/ on October 8, 2025

Committee on Tactical Combat Casualty Care (2023) Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel. Defense Health Agency, Joint Trauma System. Retrieved from https://jts.health.mil on October 8. 2025

National Association of Emergency Medical Technicians NAEMT (2020) TECC: Tactical Emergency Casualty Care Course Book (2nd Ed). Burlington, MA: Jones & Bartlett Learning

National Association of Emergency Medical Technicians NAEMT (2023) Tactical Emergency Casualty Care (TECC) Guidelines. NAEMT Education Division

National Association of Emergency Medical Technicians NAEMT (2025) 

PHTLS: Prehospital Trauma Life Support, Military Edition eBook (10th Ed). Burlington, MA: Jones & Bartlett Learning