Latest ACLS Guidelines
The 2018 American Heart Association guidelines prioritize high-quality CPR and early defibrillation as the only interventions proven to improve survival, with either amiodarone or lidocaine now considered equally acceptable for shock-refractory VF/pVT (replacing amiodarone's previous first-line status). 1
Core CPR Quality Standards
The foundation of successful resuscitation depends on these specific parameters:
- Compression depth: Push hard at least 2 inches (5 cm) 1, 2
- Compression rate: 100-120 compressions per minute 1, 2
- Allow complete chest recoil after each compression to maximize venous return 1, 2
- Minimize interruptions in compressions—keep pauses under 10 seconds 1, 2
- Rotate compressors every 2 minutes or sooner if fatigued to maintain quality 1, 2
- Avoid excessive ventilation which impairs cardiac output 1, 2
Compression-to-Ventilation Ratios
- Without advanced airway: 30:2 compression-ventilation ratio 1, 2
- With advanced airway: Continuous compressions with 1 breath every 6 seconds (10 breaths/min) 1, 2
Rhythm-Based Management Algorithm
Shockable Rhythms (VF/Pulseless VT)
Immediate defibrillation is the priority for witnessed arrest 2. For unwitnessed arrest, provide 2 minutes of CPR before the first shock 2.
For shock-refractory VF/pVT after defibrillation attempts:
This represents a key change from previous guidelines that favored amiodarone, as no antiarrhythmic has demonstrated improved long-term survival or neurological outcomes 1. The recommendation is based solely on short-term outcomes like ROSC and survival to hospital admission 1.
Non-Shockable Rhythms (PEA/Asystole)
- Focus on high-quality CPR and identifying reversible causes 2
- Early epinephrine administration (1 mg IV every 3-5 minutes) 2
- Atropine is no longer recommended for routine use in PEA/asystole 3
Advanced Airway Management
Do not interrupt compressions for prolonged periods during airway placement 2:
- Use endotracheal intubation or supraglottic airway 1, 2
- Waveform capnography is mandatory to confirm and monitor tube placement 1, 2
- Once placed, deliver 1 breath every 6 seconds with continuous compressions 1, 2
Monitoring CPR Quality
Use quantitative waveform capnography and arterial pressure monitoring when available 1, 2:
- PETCO₂ <10 mm Hg: Indicates poor CPR quality—improve compressions immediately 1, 2
- Arterial diastolic pressure <20 mm Hg: Indicates inadequate coronary perfusion—improve compressions 1, 2
Recognition of ROSC
Stop and check for ROSC when you observe 1:
- Pulse and blood pressure return 1
- Abrupt sustained increase in PETCO₂ (typically ≥40 mm Hg) 1, 2
- Spontaneous arterial pressure waves on intra-arterial monitoring 1
Post-Cardiac Arrest Care
The 2010 guidelines added post-cardiac arrest care as the fifth link in the Chain of Survival 2, 3:
- Maintain MAP ≥65 mmHg with vasopressors 4
- Target SpO₂ 92-98% to avoid hyperoxemia 4
- Perform immediate 12-lead ECG 4
- Consider coronary angiography if ischemia suspected 4
- Initiate targeted temperature management if patient doesn't follow commands 4, 3
- Prophylactic lidocaine may be considered in specific circumstances to prevent VF/pVT recurrence, though insufficient evidence exists for routine amiodarone use post-ROSC 1, 2
Critical Pitfalls to Avoid
- Delaying compressions to check for pulse—assume cardiac arrest if unresponsive with no breathing or only gasping 5
- Misinterpreting agonal gasping as normal breathing 5
- Excessive ventilation which decreases cardiac output 1, 2
- Prolonged interruptions for rhythm checks, defibrillation, or airway management 1, 2
- Using double sequential defibrillation for refractory rhythms—not established as effective (Class 2b, LOE C-LD) 2
Vascular Access
The optimal sequence and timing of ACLS interventions remain unknown and must be adapted based on the number of providers, their skill levels, and ability to secure vascular access 1, 2.