What are the steps in Cardiopulmonary Resuscitation (CPR) and Advanced Cardiovascular Life Support (ACLS) including medications and Electrocardiogram (ECG) monitoring?

Cardiopulmonary Resuscitation (CPR) and Advanced Cardiovascular Life Support (ACLS)

Immediately begin high-quality chest compressions at a depth of at least 2 inches (5 cm) and rate of 100-120 per minute with minimal interruptions, using a 30:2 compression-to-ventilation ratio for single rescuers, and defibrillate shockable rhythms as soon as possible while administering epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms. 1, 2

Initial Assessment and Activation

• Verify scene safety and check for responsiveness by shouting and tapping the patient 1
• Simultaneously assess for normal breathing (or only gasping) and check for a pulse within 10 seconds 1
• Immediately activate the emergency response system and retrieve an automated external defibrillator (AED) if the patient has no pulse or no normal breathing 1, 2
• If a witnessed sudden collapse occurs, activate emergency services and retrieve the AED before starting CPR 1

High-Quality CPR Technique

Chest compressions are the foundation of successful resuscitation and must be optimized to maintain coronary and cerebral perfusion. 1, 3

• Position compressions over the center of the mid-sternum with your body weight directly over the middle of the chest 3
• Push hard with a depth of at least 2 inches (5 cm) in adults, or at least one-third of the anteroposterior diameter in children 1
• Maintain a rate of 100-120 compressions per minute 1
• Allow complete chest recoil between each compression without leaning on the chest 1
• Minimize interruptions in compressions to less than 10 seconds 1
• Change the compressor every 2 minutes or sooner if fatigued to maintain quality 1

Compression-to-Ventilation Ratios

• Single rescuer: Use 30 compressions to 2 breaths for all ages except newborns 1
• Two rescuers (pediatric): Use 15 compressions to 2 breaths 1
• Two rescuers (adult): Use 30 compressions to 2 breaths 1
• With advanced airway in place: Provide continuous compressions at 100-120/minute with 1 breath every 6 seconds (10 breaths/minute) 1

Ventilation Management

• Deliver each rescue breath over 1 second with sufficient volume to achieve visible chest rise 1
• Avoid excessive ventilation which increases intrathoracic pressure and decreases cardiac output 1, 4
• Without an advanced airway, provide 2 breaths after every 30 compressions (single rescuer) or 15 compressions (two rescuers in pediatrics) 1
• Administer supplemental oxygen as soon as available 1

Rhythm Assessment and Defibrillation

• Use the AED or manual defibrillator as soon as it becomes available 1, 2
• Check the cardiac rhythm after 2 minutes of CPR 1

For Shockable Rhythms (VF/Pulseless VT)

• Deliver one shock immediately and resume CPR for 2 minutes before rechecking rhythm 1, 2
• Do not delay defibrillation to establish IV access or administer medications 1
• Continue cycles of shock delivery followed by 2 minutes of CPR 1

For Non-Shockable Rhythms (Asystole/PEA)

• Resume CPR immediately for 2 minutes before rechecking rhythm 1
• Continue CPR while establishing vascular access and administering medications 1, 2

Important caveat: ECG rhythm alone poorly predicts actual mechanical cardiac activity, with sensitivity of only 54-64% for detecting cardiac motion 5. Point-of-care ultrasound can identify patients with ongoing mechanical activity who may benefit from different treatment approaches 5.

Vascular Access and Medication Administration

• Establish intravenous (IV) or intraosseous (IO) access for medication delivery 1
• Use a central venous catheter when possible for amiodarone administration to reduce phlebitis risk 6

Epinephrine (All Rhythms)

• Administer 1 mg IV/IO every 3-5 minutes throughout the resuscitation 1, 2
• Pediatric dose: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL concentration), maximum 1 mg 1
• If no IV/IO access in pediatrics, may give endotracheal dose of 0.1 mg/kg (0.1 mL/kg of 1 mg/mL concentration) 1

Antiarrhythmic Drugs (Shock-Refractory VF/Pulseless VT)

Either amiodarone or lidocaine may be considered for shock-refractory VF/pulseless VT, as neither has demonstrated superiority for long-term survival or neurological outcome. 1

Amiodarone

• First dose: 300 mg IV/IO bolus 1
• Second dose: 150 mg IV/IO 1
• Pediatric dose: 5 mg/kg bolus, may repeat up to 3 total doses 1
• Must be delivered by volumetric infusion pump through a dedicated line 6
• For infusions longer than 1 hour, do not exceed concentrations of 2 mg/mL unless using a central line 6

Lidocaine

• First dose: 1-1.5 mg/kg IV/IO 1
• Second dose: 0.5-0.75 mg/kg IV/IO 1
• Pediatric dose: Initial 1 mg/kg loading dose 1
• May be considered after ROSC to prevent VF/pVT recurrence in specific circumstances (e.g., during transport) 1

Advanced Airway Management

• Place an endotracheal tube or supraglottic airway device when trained personnel are available 1, 2
• Confirm tube placement immediately using waveform capnography or capnometry 1, 4
• Once advanced airway is secured, provide 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions 1, 4
• Monitor end-tidal CO₂ (ETCO₂) continuously; if ETCO₂ <10 mmHg, attempt to improve CPR quality 1

Monitoring CPR Quality

• Use quantitative waveform capnography to monitor ventilation and CPR effectiveness 1
• If available, monitor intra-arterial pressure; diastolic pressure <20 mmHg indicates need to improve CPR quality 1
• An abrupt sustained increase in ETCO₂ (typically >40 mmHg) suggests return of spontaneous circulation 1, 4

Recognition of Return of Spontaneous Circulation (ROSC)

• Check for pulse and blood pressure 1, 4
• Monitor for abrupt sustained increase in ETCO₂ to typically >40 mmHg 1, 4
• Observe for spontaneous arterial pressure waves if intra-arterial monitoring is in place 1, 4

Post-ROSC Care

• Maintain mean arterial pressure ≥65 mmHg using vasopressors as needed 2, 4
• Target oxygen saturation of 92-98% (or 94-98% per some sources) to avoid both hypoxemia and hyperoxemia 4
• Maintain normocapnia by adjusting ventilation and monitoring with capnography 4
• Obtain 12-lead ECG immediately to identify ST-elevation myocardial infarction 4
• Consider urgent coronary angiography for suspected cardiac etiology, particularly with ST-elevation 4
• Initiate targeted temperature management for patients who do not follow commands after ROSC 4

Reversible Causes (H's and T's)

Systematically evaluate and treat the following reversible causes throughout resuscitation 4:

• Hypovolemia: Administer IV fluids 4
• Hypoxia: Ensure adequate oxygenation 4
• Hydrogen ion (acidosis): Correct with adequate ventilation 4
• Hypo/hyperkalemia: Check and correct electrolytes 4
• Hypothermia: Rewarm if accidental hypothermia caused arrest 4
• Tension pneumothorax: Perform needle decompression if suspected 4
• Tamponade (cardiac): Consider pericardiocentesis 4
• Toxins: Administer specific antidotes if available 4
• Thrombosis (pulmonary): Consider thrombolytics or mechanical intervention 4
• Thrombosis (coronary): Evaluate for acute coronary syndrome 4

Key Pitfalls to Avoid

• Do not interrupt compressions for more than 10 seconds except for rhythm checks and shock delivery 1
• Do not hyperventilate as this decreases cerebral blood flow and cardiac output 1, 4
• Do not delay defibrillation to establish IV access or give medications in shockable rhythms 1
• Do not use high-dose epinephrine as it provides no benefit over standard dosing 4
• Do not rely on ECG rhythm alone to determine presence of cardiac activity; consider point-of-care ultrasound 5
• Do not administer amiodarone through peripheral veins at concentrations >2 mg/mL for infusions longer than 1 hour due to phlebitis risk 6