Recent ACLS Protocol Recommendations for Cardiac Arrest Management
The 2020 American Heart Association (AHA) ACLS guidelines emphasize high-quality CPR, early defibrillation, appropriate medication administration, and comprehensive post-cardiac arrest care as the cornerstones of effective cardiac arrest management. 1
High-Quality CPR Components
- Compression depth: At least 2 inches (5 cm)
- Compression rate: 100-120 compressions per minute
- Chest recoil: Allow complete chest recoil after each compression
- Minimize interruptions: Keep pauses in chest compressions under 10 seconds
- Compression-ventilation ratio: 30:2 without advanced airway; continuous compressions with 1 breath every 6 seconds (10 breaths/min) with advanced airway
- Compressor rotation: Every 2 minutes or sooner if fatigued 1, 2
Cardiac Arrest Algorithm
Initial Steps
- Recognize cardiac arrest (unresponsive, no normal breathing)
- Activate emergency response system
- Begin high-quality CPR immediately
- Attach monitor/defibrillator
- Assess rhythm 1, 2
For Shockable Rhythms (VF/pVT)
- Deliver shock (200J for biphasic defibrillator)
- Resume CPR immediately for 2 minutes
- Establish IV/IO access
- Administer epinephrine 1 mg IV/IO every 3-5 minutes
- After second shock, consider antiarrhythmic:
For Non-Shockable Rhythms (Asystole/PEA)
- Continue CPR
- Establish IV/IO access
- Administer epinephrine 1 mg IV/IO every 3-5 minutes
- Consider advanced airway
- Identify and treat reversible causes 1, 2
Advanced Airway Management
- Consider endotracheal intubation or supraglottic airway
- Use waveform capnography to confirm and monitor tube placement
- After advanced airway placement, deliver 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions
- Monitor PETCO2 (< 10 mm Hg suggests need to improve CPR quality; > 40 mm Hg may indicate ROSC) 1, 2
Medication Updates
- Epinephrine: Improves survival, particularly in non-shockable rhythms 1
- Antiarrhythmics: Either amiodarone or lidocaine can be used for shock-refractory VF/pVT (updated from previous guidelines that favored amiodarone) 1
- Atropine: No longer recommended for routine use in PEA or asystole 3
Post-Cardiac Arrest Care
- Optimize ventilation and oxygenation
- Perform 12-lead ECG to identify STEMI or other cardiac pathology
- Implement targeted temperature management for comatose patients
- Optimize hemodynamics
- Identify and treat the underlying cause of arrest 1, 2
Special Considerations
Pregnant Patients
- Manual left uterine displacement for pregnant patients with uterus at or above umbilicus
- Consider perimortem cesarean delivery if no ROSC within 4 minutes 2
Refractory VF
- Consider ECMO-facilitated resuscitation for refractory VF in appropriate settings
- Recent evidence shows significantly improved survival with ECMO compared to standard ACLS (43% vs 7% survival to hospital discharge) 4
Mechanical Chest Compressions
- Reasonable alternative when sustained high-quality manual compressions are impractical or compromise provider safety
- Not superior to high-quality manual compressions 2, 5
Common Pitfalls to Avoid
- Delayed defibrillation: Success rates decline by 2-7% per minute delay
- Excessive interruptions in chest compressions: Maintain compression fraction > 60%
- Inadequate compression depth or rate: Ensure proper technique
- Hyperventilation: Avoid excessive ventilation rates
- Delayed epinephrine administration: Associated with decreased survival
- Failure to identify reversible causes: Remember the H's and T's (Hypovolemia, Hypoxia, Hydrogen ion/acidosis, Hypo/hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis-pulmonary, Thrombosis-coronary) 1, 2
The 2020 AHA guidelines emphasize that high-quality CPR and early defibrillation remain the interventions most strongly associated with improved survival in cardiac arrest, with medications playing a supportive role in the overall resuscitation effort 1.