What are the initial steps for advanced life support in cardiac arrest management?

Advanced Life Support in Cardiac Arrest Management

Immediately begin high-quality CPR with chest compressions at least 2 inches (5 cm) deep at a rate of 100-120 per minute, establish IV/IO access, administer epinephrine 1 mg every 3-5 minutes, and defibrillate shockable rhythms as soon as possible. 1

Initial Assessment and CPR Initiation

Check for responsiveness and pulse simultaneously within 10 seconds while assessing for normal breathing. 1 If no pulse is detected or the patient is only gasping:

• Activate the emergency response system immediately and retrieve an AED and emergency equipment 1
• Start CPR without delay using cycles of 30 compressions and 2 breaths 1
• Push hard and fast: compressions must be at least 2 inches (5 cm) deep at a rate of 100-120 per minute with complete chest recoil between compressions 1, 2
• Minimize interruptions in chest compressions to less than 10 seconds 1, 2
• Change compressors every 2 minutes or sooner if fatigued to maintain quality 1, 2

Rhythm Assessment and Defibrillation

Check the cardiac rhythm after 2 minutes of CPR. 1

For shockable rhythms (VF/pulseless VT):

• Deliver one shock immediately using biphasic defibrillator at manufacturer recommendation (typically 120-200 Joules initially) or 360 Joules for monophasic 1
• Resume CPR immediately for 2 minutes without pausing to check rhythm 1
• Recheck rhythm after 2 minutes and repeat this cycle 1

For non-shockable rhythms (asystole/PEA):

• Continue CPR for 2 minutes before rechecking rhythm 1
• Do not attempt defibrillation 1

Vascular Access and Medication Administration

Establish IV or IO access as soon as possible during CPR without interrupting compressions. 1, 2

Epinephrine dosing:

• Administer 1 mg IV/IO every 3-5 minutes throughout the resuscitation for all cardiac arrest rhythms 1, 2
• Continue this dosing schedule until return of spontaneous circulation (ROSC) or termination of resuscitation 1

Antiarrhythmic therapy for refractory VF/pulseless VT:

• Amiodarone: 300 mg IV/IO bolus first dose, then 150 mg second dose 1
• Lidocaine (alternative): 1-1.5 mg/kg IV/IO first dose, then 0.5-0.75 mg/kg second dose 1

Critical pitfall: High-dose epinephrine (>1 mg) does not improve survival or neurologic outcomes and may worsen outcomes in some patients. 3, 4 Always use standard 1 mg dosing.

Advanced Airway Management

Place an endotracheal tube or supraglottic airway device when trained personnel are available, but do not interrupt chest compressions for prolonged periods. 1, 2

Confirm tube placement immediately using waveform capnography or capnometry—this is mandatory, not optional. 1, 2

Once advanced airway is secured:

• Provide 1 breath every 6 seconds (10 breaths/minute) 1, 2
• Continue chest compressions without pausing for ventilations 1, 2
• Avoid excessive ventilation, which increases intrathoracic pressure and decreases cardiac output 1

Systematic Evaluation of Reversible Causes

Continuously assess and treat the "H's and T's" throughout resuscitation: 1, 5

H's:

• Hypovolemia: Administer IV fluids 1, 5
• Hypoxia: Ensure adequate oxygenation and ventilation 1, 5
• Hydrogen ion (acidosis): Correct with adequate ventilation 1, 5
• Hypo/hyperkalemia: Check and correct electrolytes 1, 5
• Hypothermia: Rewarm if accidental hypothermia present 1, 5

T's:

• Tension pneumothorax: Perform needle decompression if suspected 1, 5
• Tamponade (cardiac): Consider pericardiocentesis 1, 5
• Toxins: Administer specific antidotes if available 1, 5
• Thrombosis (pulmonary): Consider thrombolytics 1, 5
• Thrombosis (coronary): Evaluate for acute coronary syndrome 1, 5

Recognition of ROSC

Confirm ROSC by detecting: 1, 5

• Palpable pulse and measurable blood pressure 1, 5
• Abrupt sustained increase in PETCO2 (typically ≥40 mmHg)—this is the most reliable indicator during ongoing CPR 1, 5
• Spontaneous arterial pressure waves with intra-arterial monitoring 1, 5

Post-ROSC Care

Once ROSC is achieved, immediately initiate post-cardiac arrest care: 2, 5

• Maintain mean arterial pressure ≥65 mmHg using vasopressors as needed 2, 5
• Target oxygen saturation 92-98% to avoid both hypoxemia and hyperoxemia 2, 5
• Obtain 12-lead ECG immediately to identify ST-elevation myocardial infarction 5
• Consider urgent coronary angiography for suspected cardiac etiology, particularly with ST-elevation 5
• Initiate targeted temperature management for patients who do not follow commands after ROSC 5

Critical pitfall: Avoid hyperventilation post-ROSC, as it decreases cerebral blood flow and worsens neurologic outcomes. 5