What is the recommended initial dose and management protocol for cardiac arrest according to Advanced Cardiovascular Life Support (ACLS) protocol?

Advanced Cardiovascular Life Support (ACLS) Protocol for Cardiac Arrest

According to the 2020 American Heart Association guidelines, the recommended initial dose for epinephrine in adult cardiac arrest is 1 mg IV/IO every 3-5 minutes throughout resuscitation efforts. 1

Initial Management Algorithm

High-Quality CPR

• Push hard (at least 2 inches/5 cm) and fast (100-120/min)
• Allow complete chest recoil
• Minimize interruptions in compressions
• Avoid excessive ventilation
• Change compressor every 2 minutes, or sooner if fatigued 1

Rhythm Assessment and Shock Delivery

1. Check rhythm immediately

2. If VF/pVT (shockable):

   • Deliver shock (Biphasic: 120-200J per manufacturer recommendation; Monophasic: 360J)
   • Resume CPR immediately for 2 minutes
   • Establish IV/IO access during CPR

3. If Asystole/PEA (non-shockable):

   • Resume CPR immediately for 2 minutes
   • Establish IV/IO access during CPR 1

Medication Administration Protocol

Epinephrine

• First dose: 1 mg IV/IO as soon as possible for non-shockable rhythms
• For shockable rhythms: administer after first shock if rhythm remains shockable
• Subsequent doses: 1 mg IV/IO every 3-5 minutes throughout resuscitation 1

Antiarrhythmic Medications (for refractory VF/pVT)

• Amiodarone: First dose: 300 mg IV/IO bolus; Second dose: 150 mg IV/IO 1
• Alternative - Lidocaine: First dose: 1-1.5 mg/kg IV/IO; Second dose: 0.5-0.75 mg/kg IV/IO 1

Advanced Airway Management

• Endotracheal intubation or supraglottic advanced airway
• Confirm placement with waveform capnography
• Once advanced airway is placed, deliver 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions 1

Common Pitfalls to Avoid

1. Interrupting chest compressions: Minimize interruptions to less than 10 seconds for rhythm checks and defibrillation
2. Delayed epinephrine administration: Don't delay giving epinephrine while waiting for advanced airway placement
3. Excessive ventilation: Avoid rapid or forceful breaths which can increase intrathoracic pressure and decrease venous return
4. Failure to consider reversible causes: Always consider and treat potential reversible causes (Hypovolemia, Hypoxia, Hydrogen ion/acidosis, Hypo/hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis-pulmonary, Thrombosis-coronary) 1

Evidence Considerations

While some research has explored alternative dosing strategies for epinephrine, including lower doses (0.5 mg) 2 or higher doses (5-7 mg) 3, these approaches have not shown improved survival or neurological outcomes compared to the standard 1 mg dose. A systematic review from 2023 found that administering epinephrine at intervals <3 minutes or >5 minutes was not associated with better hospital outcomes compared to the recommended 3-5 minute interval 4.

The 2020 AHA guidelines maintain the recommendation of 1 mg epinephrine every 3-5 minutes as the standard approach, which remains the most evidence-based protocol for maximizing survival outcomes in cardiac arrest 1.