What are the immediate steps for cardiac advanced life support (CALS) in a patient with cardiac arrest?

Immediate Steps for Cardiac Advanced Life Support (CALS) in Cardiac Arrest

The immediate steps for cardiac advanced life support in a patient with cardiac arrest involve high-quality CPR with minimal interruptions, early defibrillation for shockable rhythms, establishing IV/IO access for medication administration, and following the appropriate algorithm based on the cardiac rhythm.

Initial Assessment and Basic Life Support

• Check for responsiveness, breathing, and pulse simultaneously (within 10 seconds) 1
• If no pulse is detected, immediately begin high-quality chest compressions 1
• Perform chest compressions at a rate of 100-120 compressions per minute 1
• Push hard (at least 2 inches/5 cm in adults) and allow complete chest recoil 1
• Minimize interruptions in compressions to achieve at least 60 compressions per minute 1
• If no advanced airway is in place, use a 30:2 compression-to-ventilation ratio 1
• Attach monitor/defibrillator as soon as available 1

Rhythm Assessment and Defibrillation

• After 2 minutes of CPR, pause briefly to check rhythm 1
• For shockable rhythms (VF/pVT):
  • Deliver one shock immediately (biphasic: 120-200J per manufacturer recommendation; monophasic: 360J) 1
  • Resume CPR immediately after shock for 2 minutes before reassessing rhythm 1
• For non-shockable rhythms (PEA/asystole):
  • Continue CPR without defibrillation 1
  • Reassess rhythm every 2 minutes 1

Vascular Access and Medication Administration

• Establish IV/IO access while CPR is ongoing 1
• For all rhythms: Administer epinephrine 1 mg IV/IO every 3-5 minutes 1
  • For non-shockable rhythms: Give first dose as soon as vascular access is established 1
  • For shockable rhythms: Give first dose after the second shock or if rhythm becomes non-shockable 1
• For persistent or recurrent VF/pVT after initial shock:
  • Administer amiodarone 300 mg IV/IO bolus for first dose, followed by 150 mg for second dose if needed 1
  • Alternatively, lidocaine 1-1.5 mg/kg IV/IO for first dose, followed by 0.5-0.75 mg/kg for second dose if needed 1

Advanced Airway Management

• Consider advanced airway placement (endotracheal intubation or supraglottic airway) 1
• Confirm placement with waveform capnography 1
• Once advanced airway is placed, provide continuous chest compressions without pauses for ventilation 1
• Deliver 1 breath every 6 seconds (10 breaths/min) asynchronously with compressions 1

CPR Quality and Team Dynamics

• Change compressor every 2 minutes (or sooner if fatigued) to maintain high-quality compressions 1
• Monitor CPR quality using quantitative waveform capnography if available (PETCO2 typically <10 mmHg during CPR) 1
• Assign team roles and perform actions simultaneously rather than sequentially 1, 2
• Minimize interruptions in chest compressions for any intervention 1

Identifying and Treating Reversible Causes

• Consider and treat potential reversible causes (the "H's and T's") 1:
  • Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia 1
  • Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary) 1

Post-Resuscitation Care

• Upon return of spontaneous circulation (ROSC), begin post-cardiac arrest care 1
• Monitor for signs of ROSC: pulse, blood pressure, abrupt sustained increase in PETCO2 (typically >40 mmHg), or spontaneous arterial pressure waves with intra-arterial monitoring 1
• Consider targeted temperature management for patients who do not follow commands after ROSC 1

Common Pitfalls to Avoid

• Delivering excessive ventilation, which can compromise venous return and decrease cerebral blood flow 1, 2
• Prolonged pauses in chest compressions, which significantly decrease survival rates 2
• Failing to change compressors frequently, leading to fatigue and decreased compression quality 1, 3
• Delaying defibrillation for shockable rhythms, which reduces chances of successful conversion 1
• Administering medications through peripheral IV without a flush or elevation of the extremity 1