ACLS Protocol for Cardiac Arrest Management
The 2020 American Heart Association ACLS protocol for cardiac arrest management emphasizes high-quality CPR with minimal interruptions, early defibrillation for shockable rhythms, administration of epinephrine every 3-5 minutes, and addressing potentially reversible causes as the cornerstone of effective resuscitation. 1
Initial Assessment and Basic Life Support
Recognition of Cardiac Arrest
- Check for responsiveness
- Shout for nearby help
- Activate emergency response system
- Get AED and emergency equipment (or send someone to do so)
- Check for breathing and pulse simultaneously (take no more than 10 seconds)
- If no definitive pulse is felt within 10 seconds, begin CPR 1
High-Quality CPR
- Push hard (at least 2 inches/5 cm) and fast (100-120/min)
- Allow complete chest recoil between compressions
- Minimize interruptions in chest compressions
- Avoid excessive ventilation
- Rotate compressor every 2 minutes or sooner if fatigued 1, 2
- Compression-to-ventilation ratio of 30:2 if no advanced airway
Advanced Cardiac Life Support Algorithm
Rhythm Assessment and Defibrillation
- Check rhythm every 2 minutes (minimize interruptions to <10 seconds)
- For shockable rhythms (VF/pVT):
- Deliver shock immediately
- Resume CPR immediately for 2 minutes after shock
- Reassess rhythm after 2 minutes 1
- For non-shockable rhythms (PEA/Asystole):
- Continue CPR
- Reassess rhythm every 2 minutes 1
Medication Administration
- Establish IV/IO access as soon as possible
- For shockable rhythms:
- For non-shockable rhythms:
- Epinephrine 1 mg IV/IO as soon as possible, then every 3-5 minutes
- Atropine is no longer recommended for routine use in asystole 2
Advanced Airway Management
- Initial management may begin with basic airway techniques (bag-mask ventilation)
- Options for advanced airway include:
- Endotracheal intubation
- Supraglottic airway device 1
- Confirm placement with:
- Waveform capnography (preferred method)
- Chest rise observation
- Auscultation over epigastrium and bilateral lung fields 1
- After advanced airway placement:
- Deliver continuous chest compressions without pauses for ventilation
- Provide 10 breaths per minute (1 breath every 6 seconds) 1
Addressing Reversible Causes (H's and T's)
H's
- Hypovolemia: IV/IO fluid administration
- Hypoxia: Ensure adequate oxygenation and ventilation
- Hydrogen ion (acidosis): Consider sodium bicarbonate for severe acidosis (pH < 7.1)
- Hypo/Hyperkalemia: Appropriate electrolyte therapy
- Hypothermia: Active rewarming 2
T's
- Tension pneumothorax: Needle decompression
- Tamponade (cardiac): Pericardiocentesis
- Toxins: Specific antidotes if applicable
- Thrombosis (pulmonary): Consider empiric fibrinolytic therapy
- Thrombosis (coronary): Reperfusion strategies 2
Monitoring During Resuscitation
- Continuous capnography to assess CPR quality and detect ROSC
- Arterial pressure monitoring if available
- Echocardiography can guide management by providing information about cardiac function and potential causes 2
Post-Cardiac Arrest Care
After ROSC:
- Optimize oxygenation and ventilation (avoid hyperoxia)
- Maintain systolic BP >90 mmHg
- Consider targeted temperature management for comatose patients
- Obtain 12-lead ECG
- Consider emergent cardiac catheterization for suspected cardiac etiology 2
Common Pitfalls to Avoid
- Interrupting chest compressions for prolonged periods
- Delivering excessive ventilation (hyperventilation reduces venous return)
- Delayed or inappropriate defibrillation
- Failure to consider and treat reversible causes
- Delayed administration of epinephrine in non-shockable rhythms
- Failure to confirm and monitor advanced airway placement 1
ACLS is a systematic approach to cardiac arrest management that requires regular training and practice to maintain proficiency. The foundation of successful resuscitation remains high-quality CPR with minimal interruptions and early defibrillation when indicated 3.