What are the steps for managing cardiac arrest according to Advanced Cardiovascular Life Support (ACLS)?

ACLS Cardiac Arrest Management

Begin high-quality CPR immediately upon recognizing cardiac arrest, starting with chest compressions at a rate of 100-120/min and depth of at least 2 inches, while simultaneously activating the emergency response system and obtaining a defibrillator. 1

Initial Recognition and Response

• Check responsiveness, breathing, and pulse simultaneously within 10 seconds - if no definite pulse is felt, assume cardiac arrest and begin CPR immediately 1, 2
• Activate emergency response system and retrieve AED/defibrillator as soon as cardiac arrest is recognized 1
• Do not delay CPR to check for a pulse - healthcare providers frequently take too long (>10 seconds) and have difficulty determining pulse presence, so if uncertain, start compressions 1

High-Quality CPR Technique

CPR quality is the foundation of successful resuscitation and must be optimized throughout the arrest:

• Push hard (at least 2 inches/5 cm depth) and fast (100-120 compressions/min) with complete chest recoil between compressions 1, 2
• Minimize interruptions in chest compressions - keep all pauses under 10 seconds, including for rhythm checks and defibrillation 1, 2
• Perform 30 compressions to 2 ventilations until an advanced airway is placed 1
• Rotate compressors every 2 minutes or sooner if fatigued to maintain compression quality 1
• Avoid excessive ventilation, which impedes venous return 1

Rhythm Identification and Defibrillation

Attach monitor/defibrillator pads immediately to identify the cardiac rhythm - this determines your treatment pathway 2:

For VF/Pulseless VT (Shockable Rhythms):

• Deliver one shock as soon as the defibrillator is available 1, 2
• Use biphasic energy at manufacturer recommendation (typically 120-200 joules initial dose); if unknown, use maximum available 1
• Use 360 joules for monophasic defibrillators 1
• Resume CPR immediately after shock delivery without pausing for pulse or rhythm check - begin with chest compressions 1
• Continue CPR for 2 minutes, then recheck rhythm 1

For PEA/Asystole (Non-Shockable Rhythms):

• Do not attempt defibrillation - immediately resume CPR for 2 minutes 1
• Focus on identifying and treating reversible causes (H's and T's) 1
• Recheck rhythm every 2 minutes 1

Medication Administration

Establish IV or IO access without interrupting chest compressions 1:

• Epinephrine 1 mg IV/IO every 3-5 minutes throughout the arrest for all rhythms 1, 2
• For shockable rhythms (VF/pVT), administer epinephrine after the second shock 1

Antiarrhythmic Therapy for Refractory VF/pVT:

After 2-3 unsuccessful shocks, consider antiarrhythmic medication 2:

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

Note: While both drugs are recommended in ACLS guidelines 1, recent evidence suggests lidocaine may be associated with slightly better outcomes for in-hospital cardiac arrest, though both remain acceptable choices 3. The 2020 AHA guidelines support either agent 1.

Advanced Airway Management

• Consider advanced airway placement (endotracheal tube or supraglottic airway) without interrupting chest compressions 1, 2
• Confirm placement with continuous waveform capnography - this is mandatory, not optional 1, 2
• Once advanced airway is placed, deliver 1 breath every 6 seconds (10 breaths/min) with continuous uninterrupted chest compressions - no longer use 30:2 ratio 1, 2

Common pitfall: Providers often hyperventilate patients after advanced airway placement. Stick to exactly 10 breaths per minute to avoid impeding venous return and decreasing cardiac output 1.

Monitoring During Resuscitation

Use quantitative waveform capnography to guide resuscitation quality 2:

• Target PETCO₂ >10 mmHg - if lower, improve CPR quality (push harder, faster, minimize interruptions) 1, 2
• Abrupt sustained increase in PETCO₂ to ≥40 mmHg indicates ROSC 1
• Do not use PETCO₂ alone to predict mortality or terminate resuscitation 2

Reversible Causes (H's and T's)

Actively search for and treat reversible causes throughout the resuscitation 1:

• Hypovolemia - give fluid boluses
• Hypoxia - ensure adequate oxygenation and ventilation
• Hydrogen ion (acidosis) - consider bicarbonate for severe acidosis or hyperkalemia 1
• Hypo/Hyperkalemia - give calcium for hyperkalemia 1
• Hypothermia - continue resuscitation until rewarmed 1, 2
• Tension pneumothorax - needle decompression
• Tamponade (cardiac) - pericardiocentesis
• Toxins - consider antidotes, contact poison control 1
• Thrombosis (pulmonary) - consider thrombolytics
• Thrombosis (coronary) - prepare for emergent catheterization

Return of Spontaneous Circulation (ROSC)

Recognize ROSC by the presence of 1:

• Palpable pulse and measurable blood pressure
• Abrupt sustained increase in PETCO₂ (typically ≥40 mmHg)
• Spontaneous arterial pressure waves on invasive monitoring

Post-ROSC Management:

• Maintain oxygenation avoiding both hypoxia and hyperoxia 2
• Maintain hemodynamic stability - norepinephrine is the preferred vasopressor for post-ROSC hypotension 4
• Consider emergent coronary angiography for patients with ST-elevation or suspected acute coronary syndrome 2

Special Populations

• Pregnant patients: Perform manual left uterine displacement to relieve aortocaval compression throughout resuscitation 2
• Hypothermic patients: Continue resuscitation efforts until core temperature is normalized - "not dead until warm and dead" 1, 2
• Witnessed arrests with shockable rhythms: Consider ECPR (extracorporeal CPR) if conventional CPR is failing and resources are available 2

Critical Algorithm Summary

1. Recognize arrest → Start compressions immediately
2. Activate emergency response → Get defibrillator
3. High-quality CPR → 100-120/min, ≥2 inches depth, minimize interruptions
4. Check rhythm every 2 minutes:
   • Shockable (VF/pVT) → Shock → Resume CPR → Epinephrine after 2nd shock → Antiarrhythmic after 2-3 shocks
   • Non-shockable (PEA/Asystole) → Resume CPR → Epinephrine immediately → Search for reversible causes
5. Continue until ROSC or termination criteria met

The most common error in ACLS is poor CPR quality with excessive interruptions 1. Prioritize continuous, high-quality chest compressions above all other interventions except defibrillation for shockable rhythms.