What is the immediate management protocol for cardiac arrest using ACLS (Advanced Cardiovascular Life Support) and EKG (Electrocardiogram) strips?

Immediate Management Protocol for Cardiac Arrest Using ACLS and EKG Strips

The immediate management of cardiac arrest requires prompt recognition of the arrest rhythm on EKG strips followed by implementation of the appropriate ACLS algorithm, with high-quality CPR as the foundation of all interventions. 1

Initial Assessment and Recognition

• Check for responsiveness, breathing, and pulse simultaneously (within 10 seconds); if no pulse is detected, begin CPR immediately 1
• Activate the emergency response system and obtain an AED/defibrillator 1
• Attach cardiac monitor/defibrillator pads as soon as available to identify the cardiac arrest rhythm 1
• Recognize that EKG rhythm alone may not accurately predict actual mechanical cardiac activity (sensitivity 54-64%), supporting the use of additional assessment methods when available 2

High-Quality CPR

• Push hard (at least 2 inches/5 cm) and fast (100-120 compressions/min) with complete chest recoil 1
• Minimize interruptions in chest compressions, keeping pauses under 10 seconds 1
• Rotate compressors every 2 minutes to prevent fatigue and maintain compression quality 3
• For healthcare providers: perform cycles of 30 compressions to 2 ventilations until an advanced airway is placed 1
• After advanced airway placement, provide continuous compressions with 1 breath every 6-8 seconds (8-10 breaths/min) 1

Rhythm-Based Management

Shockable Rhythms (VF/pVT)

1. Defibrillation

   • For VF/pVT, deliver one shock as soon as defibrillator is available 1
   • Use manufacturer-recommended energy for biphasic defibrillators (typically 120-200J) or 360J for monophasic defibrillators 3
   • Resume CPR immediately after shock for 2 minutes before rhythm reassessment 1

2. Medication Administration

   • Establish IV/IO access while maintaining CPR 3
   • Administer epinephrine 1mg IV/IO every 3-5 minutes 1, 3
   • For refractory VF/pVT (after 2-3 shocks), consider antiarrhythmic drugs:
     • Amiodarone: first dose 300mg IV/IO bolus, second dose 150mg IV/IO 3
     • OR Lidocaine: first dose 1-1.5mg/kg IV/IO, second dose 0.5-0.75mg/kg IV/IO 3

Non-Shockable Rhythms (Asystole/PEA)

1. CPR and Medication

   • Continue high-quality CPR 1
   • Administer epinephrine 1mg IV/IO as soon as possible, repeat every 3-5 minutes 1
   • Consider advanced airway placement if not already done 1

2. Identify and Treat Reversible Causes

   • Search for and treat potentially reversible causes (5H's and 5T's) 1:
     • Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia
     • Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary)

Advanced Airway Management

• Consider advanced airway placement (endotracheal tube or supraglottic airway) without interrupting chest compressions 1
• Confirm proper placement with waveform capnography 1, 3
• After advanced airway placement, deliver 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions 1

Monitoring During Resuscitation

• Use quantitative waveform capnography to:
  • Confirm and monitor advanced airway placement 1, 3
  • Monitor CPR quality (target PETCO₂ >10 mmHg) 3
  • Note that ETCO₂ should not be used alone as a mortality predictor or to terminate resuscitation 1
• Consider cardiac ultrasound if available to identify potentially reversible causes without interrupting the ACLS protocol 1

Post-Resuscitation Care

• For patients with Return of Spontaneous Circulation (ROSC):
  • Maintain oxygenation and ventilation (avoid both hypoxia and hyperoxia) 1
  • Maintain hemodynamic stability 1
  • Perform 12-lead ECG to identify ST-elevation or other signs of acute coronary syndrome 4
  • Consider emergent coronary angiography for patients with:
    • ST-segment elevation on ECG 1
    • Shock, electrical instability, or signs of ongoing myocardial damage even without ST-elevation 1

Common Pitfalls to Avoid

• Excessive ventilation (>10 breaths/min) can decrease venous return and cardiac output 3
• Prolonged pulse checks (>10 seconds) unnecessarily interrupt chest compressions 3
• Delays in defibrillation for shockable rhythms while preparing medications 3
• Failure to identify and treat potentially reversible causes 1
• Relying solely on EKG rhythm without considering other clinical parameters 2

Special Considerations

• For pregnant patients, perform lateral uterine displacement to relieve aortocaval compression 3
• For hypothermic patients, continue resuscitation efforts until the patient is rewarmed 1
• Consider ECPR (extracorporeal CPR) for select patients when conventional CPR is failing, particularly in witnessed arrests with shockable rhythms 1