Resuscitation Council UK Guidelines 2025: one year on

Resuscitation Council UK (RCUK) published its 2025 Resuscitation Guidelines on 27 October 2025, replacing the 2021 edition, and asked organisations to implement the changes over the following 12 months. That window has now closed. If your resuscitation training predates late 2025, this is the point to check that what you practise matches what the guidelines now say, whether you work on an ambulance, an offshore installation or a dive site.

Why this matters

Cardiac arrest is common and survival is poor. RCUK’s 2025 epidemiology chapter reports around 115,000 out-of-hospital cardiac arrests a year reported to UK ambulance services, with resuscitation attempted in about 43,000. Bystanders start CPR in 60 to 73 per cent of cases, but a public defibrillator is used in fewer than 10 per cent. Thirty-day survival is 9 to 10 per cent overall.

RCUK revises its guidelines on a five-year cycle and changes them between editions only for an intervention that substantially affects outcome. Clinicians trained on the 2021 edition need to know which parts of their practice have moved on, which have not, and where the 2025 text simply places more emphasis on things they already do.

What the researchers did

The 2025 guidelines sit at the end of a four-year evidence process run by the International Liaison Committee on Resuscitation (ILCOR), which brings together nine resuscitation organisations across six task forces. The 2025 ILCOR consensus drew on 96 systematic reviews, 43 scoping reviews and 112 evidence updates, covering more than 250 topics. Recommendations were graded using GRADE, a system that rates both the certainty of the evidence and the strength of the recommendation.

The European Resuscitation Council (ERC) then wrote European guidelines from that consensus, published in the journal Resuscitation in October 2025 after a two-week public consultation. An RCUK Guidelines Working Group adapted each section to UK practice. Stakeholders included members of the public and cardiac arrest survivors. The executive summary of changes is authored by Gavin Perkins and Adam Benson Clarke.

Chapters cover epidemiology, systems, education, ethics, adult basic life support (BLS), adult advanced life support (ALS), special circumstances, post-resuscitation care, paediatric and newborn life support. First aid is a chapter in its own right for the first time. Updated RCUK courses and manuals followed from January 2026.

What they found

Adult BLS. The main change is the order of the first steps. Call 999 for any unresponsive person, then assess breathing while the call connects. In 2021, breathing was checked first. The 2025 text also notes that athletes may show near-normal or panting breathing early after arrest. Compressions remain at 100 to 120 per minute and 5 to 6 cm deep. New content covers the 999 call handler’s role and support for lay rescuers who find the event distressing. Bystander CPR and defibrillation increase survival two- to four-fold.

Adult ALS. RCUK states there are no major changes. Emphasis has shifted to effective ventilation and correct pad placement, with the lateral pad directly below the armpit in the mid-axillary line. Adrenaline 1 mg is given as soon as possible in non-shockable rhythms, after the third shock in shockable rhythms, then every 3 to 5 minutes. Amiodarone is 300 mg after three shocks and 150 mg after five. Access is intravenous (IV) first, with intraosseous (IO) if IV is not achieved rapidly within two attempts. After three failed shocks, consider antero-posterior pad placement; dual sequential defibrillation, meaning two defibrillators firing in sequence, is not recommended routinely. Tracheal intubation is for rescuers with over 95 per cent success within two attempts, using waveform capnography. Calcium, sodium bicarbonate and corticosteroids are not given routinely.

Paediatric. Use 15:2 if trained in paediatric BLS, otherwise 30:2, after five initial breaths. Compress the lower half of the sternum at every age, using the two-thumb encircling technique in infants, to at least one third of chest depth and never beyond 6 cm. Adrenaline is 10 micrograms per kg and the first shock 4 J per kg. Out of hospital, babies under 24 hours old follow the newborn algorithm. New sections cover special circumstances and post-resuscitation care in children.

Newborn. Less weight is given to skin colour, which is unreliable across skin tones. Two-person jaw thrust is preferred, supraglottic airways are considered early, and adrenaline is repeated every 4 minutes. Sodium bicarbonate is no longer recommended. A new out-of-hospital section asks for at least two double-crewed ambulances to an imminent birth, proactive thermal care, and IO access as first line unless the clinician can place an umbilical venous line.

First aid. Life-threatening bleeding is managed by escalation: direct pressure, then a haemostatic dressing and/or a tourniquet 5 to 7 cm above the wound, not over a joint, with the time recorded. Adult choking is up to five back blows then up to five abdominal thrusts. A second adrenaline dose in anaphylaxis follows after five minutes if symptoms persist.

Ethics. Early, person-centred conversations should be recorded in plans such as ReSPECT. Families should be offered the choice to be present during resuscitation. Termination may be considered after at least 45 minutes of ALS in persistent asystole with no reversible cause. Low end-tidal CO2 should never be the sole reason to stop.

Strengths and limitations

The process is the strength. Four years of systematic review, formal grading, public consultation and a UK adaptation step give these guidelines more weight than any single trial. The chapters say where recommendations rest on expert consensus rather than evidence; the 95 per cent intubation threshold is one example.

The limitations follow from the same process. ALS is largely unchanged because little new high-certainty evidence emerged, and the RCUK chapter pages do not quote trial outcome figures, so readers wanting the numbers behind the IV-first advice must go to the ERC and ILCOR documents. The guidance also assumes a UK system: 999 call handlers, a national defibrillator database and timely access to specialist centres. Offshore and diving teams work without a call handler and with evacuation measured in hours. The paediatric chapter does not spell out what changed in infant hand position, though the RCUK news release lists it as an update.

What it means for your practice

None of this overrides your employer’s protocols or JRCALC. Where local guidance has not yet caught up, follow it and raise the gap through your clinical governance route.

  • Everyone: rehearse the new order. Unresponsive means call 999, or your site emergency number, first, then check breathing. Treat panting or gasping as cardiac arrest.
  • First responders and first aiders: the new first aid chapter is now your reference for bleeding, choking, anaphylaxis, hypoglycaemia and heat illness. Check your tourniquet placement and timing habits against it.
  • Paramedics and ambulance clinicians: IV first, IO within two failed attempts. Check pad position before escalating energy. Prepare a vector change after three failed shocks rather than reaching for a second defibrillator. Plan for births before arrival, including a second crew and early warmth.
  • Offshore and diver medics: follow the special circumstances chapter for drowning and hypothermia: five initial ventilations with oxygen in drowning, and after three shocks no further defibrillation or adrenaline until core temperature reaches 30°C. Agree in advance with topside medical support how termination decisions will be made when evacuation is prolonged.
  • What not to change: do not alter drug doses, ratios or energy levels on the basis of this summary. Confirm them against the algorithms on resus.org.uk and your own protocol.

Reflect

  • When did you last check your own resuscitation practice against the 2025 algorithms, and what had changed?
  • How would you support a family member who wants to stay during a resuscitation attempt?
  • In your setting, what replaces the 999 call handler, and does your team’s first-minute sequence reflect the 2025 order?
  • If a shockable rhythm persisted after three shocks, what would your next three actions be?

Read the original

Published 25 October 2026. Last reviewed October 2026.

These summaries are for education and CPD only. They are not clinical guidelines. Always practise within your scope of practice and follow your employer’s protocols and national guidance such as JRCALC and Resuscitation Council UK.

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