Management of Pulseless Cardiac Arrest
Immediately begin high-quality CPR with chest compressions at a rate of 100-120/min and depth of at least 2 inches (5 cm), minimize interruptions, attach a defibrillator/monitor to identify the rhythm, establish IV/IO access, and administer epinephrine 1 mg every 3-5 minutes—with timing dependent on whether the rhythm is shockable or non-shockable. 1, 2, 3
Initial Response Algorithm
Step 1: Start CPR Immediately
- Push hard and fast: Compress at least 2 inches (5 cm) depth at 100-120 compressions/min 4, 5
- Allow complete chest recoil between compressions
- Minimize interruptions to <10 seconds
- Rotate compressors every 2 minutes to prevent fatigue 6
- Use 30:2 compression-to-ventilation ratio until advanced airway placed 7, 8
Step 2: Identify the Rhythm
Cardiac arrest presents as one of four rhythms, which dictate your treatment pathway:
Shockable Rhythms (VF/Pulseless VT):
- Deliver defibrillation immediately
- Resume CPR immediately after shock without pulse check 1, 7
- Administer epinephrine 1 mg IV/IO AFTER initial defibrillation attempts fail 2, 3
- Give amiodarone 300 mg IV/IO (or lidocaine 1-1.5 mg/kg if amiodarone unavailable) after second shock 6, 1
Non-Shockable Rhythms (PEA/Asystole):
- Continue high-quality CPR
- Administer epinephrine 1 mg IV/IO as soon as feasible—this is critical 1, 2, 3
- Repeat epinephrine every 3-5 minutes 6, 9
- Search aggressively for reversible causes (see below)
Medication Management
Epinephrine Dosing
- Standard dose: 1 mg IV/IO every 3-5 minutes 6, 2
- For non-shockable rhythms: give as soon as IV/IO access established 1, 2
- For shockable rhythms: give after initial defibrillation attempts unsuccessful 2, 3
- Pediatric dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration), max 1 mg 6
Critical caveat: While epinephrine improves ROSC and short-term survival, evidence for improved neurologically intact survival remains uncertain 1, 10. However, it remains a strong recommendation based on survival benefit 2.
Antiarrhythmics (for refractory VF/pulseless VT only)
- Amiodarone 300 mg IV/IO bolus, may repeat 150 mg once 6, 1
- Lidocaine 1-1.5 mg/kg IV/IO if amiodarone unavailable 6
- Pediatric amiodarone: 5 mg/kg bolus, may repeat up to 2 doses 9, 6
Vasopressin
Do NOT use vasopressin in place of or in addition to epinephrine—no survival benefit demonstrated 2, 10
Avoid Routine Use
- Sodium bicarbonate: Only for specific circumstances (hyperkalemia, tricyclic overdose, prolonged arrest), NOT routine use 2
- Calcium: Only for documented hypocalcemia, hyperkalemia, or calcium channel blocker toxicity 3
Vascular Access Priority
Attempt peripheral IV first 4, 3. The 2020 guidelines clarified that IV route is preferred over IO based on new evidence suggesting uncertainty about IO efficacy 4. If IV attempts fail or are not feasible, then establish IO access 4.
Advanced Airway Management
Once advanced airway (endotracheal tube or supraglottic device) is placed:
- Switch to continuous chest compressions without pauses for ventilation 6, 7
- Deliver compressions at 100-120/min continuously
- Provide ventilations at 1 breath every 6 seconds (10 breaths/min) 6
- Confirm placement with waveform capnography 9
Important pitfall: Do NOT interrupt compressions for prolonged intubation attempts. If taking >10 seconds, resume compressions and retry 7.
Rhythm Checks and Defibrillation Strategy
- Check rhythm every 2 minutes (after ~5 cycles of CPR) 1, 8
- For VF/pulseless VT: Deliver single shock, then immediately resume CPR 8
- Do NOT check pulse immediately after shock—resume compressions first 8
- Only check pulse if organized rhythm appears on monitor 6
Search for Reversible Causes (H's and T's)
Aggressively identify and treat:
H's:
- Hypovolemia (fluid bolus)
- Hypoxia (ensure oxygenation/ventilation)
- Hydrogen ion/acidosis (consider bicarbonate only if severe)
- Hypo/hyperkalemia (treat electrolyte abnormality)
- Hypothermia (rewarm)
T's:
- Tension pneumothorax (needle decompression)
- Tamponade (pericardiocentesis)
- Toxins (specific antidotes)
- Thrombosis coronary (consider PCI)
- Thrombosis pulmonary (consider thrombolytics—tPA 50-100 mg for massive PE during arrest) 11
Monitoring CPR Quality
Use physiologic feedback when available:
- ETCO₂ <10 mmHg: Improve CPR quality 1
- Diastolic arterial pressure <20 mmHg: Improve compressions 1
- Abrupt rise in ETCO₂ may indicate ROSC 6
Critical note: Do NOT use ETCO₂ alone to terminate resuscitation 3. The 2025 guidelines emphasize that termination of resuscitation decisions should follow structured TOR rules based on EMS scope of practice, not isolated ETCO₂ values 3.
Special Considerations
Torsades de Pointes
- Treat with magnesium sulfate 2 g IV (25-50 mg/kg in pediatrics, max 2 g) over several minutes 6
- Proceed with defibrillation if deteriorates to VF 6
Refractory VF/Pulseless VT
The usefulness of double sequential defibrillation and vector change has not been established 4, 3. Continue standard ACLS with high-quality CPR, epinephrine, and antiarrhythmics while addressing reversible causes.
Post-ROSC Care Transition
Once ROSC achieved:
- Maintain oxygenation (avoid hypoxia and hyperoxia) 12
- Target normocapnia 12
- Maintain adequate blood pressure (MAP >65 mmHg in adults) 12
- Initiate targeted temperature management 32-36°C for at least 24 hours if patient remains comatose 12
- Consider early cardiac catheterization if suspected cardiac etiology 12
The foundation of successful resuscitation remains uninterrupted high-quality chest compressions combined with early rhythm identification, appropriate defibrillation for shockable rhythms, timely epinephrine administration, and aggressive treatment of reversible causes 1, 7, 2, 3.