Initial Steps for Advanced Cardiovascular Life Support (ACLS) Management
The initial steps for ACLS management include immediate recognition of cardiac arrest, high-quality CPR with chest compressions at a rate of 100-120/min and depth of at least 2 inches (5 cm), early defibrillation for shockable rhythms, and minimizing interruptions in chest compressions throughout resuscitation. 1, 2, 3
Recognition of Cardiac Arrest
- Check for responsiveness, breathing (or only gasping), and pulse simultaneously within 10 seconds; if no definite pulse is felt, begin CPR immediately 1, 3
- Activate the emergency response system and obtain an AED/defibrillator as soon as possible 1, 2
- Attach cardiac monitor/defibrillator pads as soon as available to identify the cardiac arrest rhythm 3
High-Quality CPR
- Push hard (at least 2 inches/5 cm) and fast (100-120 compressions/min) with complete chest recoil after each compression 1, 2
- Minimize interruptions in chest compressions, keeping pauses under 10 seconds 1, 3
- Avoid excessive ventilation which can be detrimental to outcomes 1
- Rotate compressors every 2 minutes to prevent fatigue and maintain high-quality compressions 1, 2
- For healthcare providers without an advanced airway: perform cycles of 30 compressions to 2 ventilations 1
- After advanced airway placement: provide continuous compressions with 1 breath every 6-8 seconds (8-10 breaths/min) 1
Early Defibrillation
- For VF/pVT, deliver one shock as soon as defibrillator is available 1, 3
- Use manufacturer-recommended energy for biphasic defibrillators (typically 120-200J) or 360J for monophasic defibrillators 2, 3
- Resume CPR immediately after shock for 2 minutes before rhythm reassessment 1, 3
- Minimize the time between stopping compressions and delivering shock, and between shock and resuming compressions 1, 2
Medication Administration
- Establish IV/IO access for medication administration 2
- For VF/pVT: After the first or second shock, administer epinephrine 1mg IV/IO every 3-5 minutes 1, 2
- For refractory VF/pVT (after 2-3 shocks): Consider antiarrhythmic drugs 2, 3
Monitoring During Resuscitation
- Use quantitative waveform capnography to confirm and monitor advanced airway placement 1, 2
- Monitor CPR quality using capnography (target PETCO₂ >10 mmHg) 1, 2
- Consider arterial pressure monitoring if available (target relaxation phase pressure >20 mmHg) 1, 2
Team Dynamics
- Assign clear roles to team members, including compressor(s), airway manager, medication administrator, and team leader 2, 3
- Use closed-loop communication to ensure tasks are completed 2
- Conduct ongoing evaluation of resuscitation efforts and adjust as needed 1, 3
Common Pitfalls to Avoid
- Delaying chest compressions while setting up equipment or performing other tasks 1
- Excessive interruptions in chest compressions, including during advanced airway placement 1, 2
- Delivering too many ventilations, which can impede venous return 1
- Prolonged pulse checks; if pulse is not definitely felt within 10 seconds, resume CPR 2, 3
- Delaying defibrillation while preparing medications for shockable rhythms 2
The 2020 American Heart Association guidelines emphasize the importance of high-quality CPR as the foundation of successful ACLS, with early defibrillation for VF/pVT being critical for survival 1. While advanced interventions such as medications and advanced airways are important components of ACLS, they should never delay or interrupt high-quality chest compressions 1.