What are the steps for cardiac arrest management following the Cardiopulmonary Resuscitation (CPR) American Heart Association's (AHA) Advanced Cardiovascular Life Support (ACLS) protocol?

CPR ACLS Protocol for Cardiac Arrest Management

Follow the 2020 American Heart Association ACLS algorithm with immediate high-quality chest compressions as the cornerstone of resuscitation, minimizing interruptions and integrating early defibrillation with systematic rhythm assessment every 2 minutes. 1

Initial Recognition and Activation

Check for responsiveness by shouting and tapping the victim on the shoulder. 1

• Simultaneously assess for no breathing or only gasping while checking for a pulse (within 10 seconds maximum). 1
• If unresponsive with no pulse or only gasping, immediately activate the emergency response system and retrieve the AED/defibrillator. 1
• Healthcare providers must avoid taking too long to check for pulse—if not definitively palpated within 10 seconds, start compressions immediately. 1

High-Quality CPR: The Foundation

Begin chest compressions immediately with the following parameters: 1, 2

• Rate: 100-120 compressions per minute 1, 2
• Depth: At least 2 inches (5 cm), up to 5-6 cm 1, 2
• Allow complete chest recoil between compressions—incomplete recoil prevents cardiac refilling and reduces effectiveness 2
• Minimize interruptions in chest compressions to less than 10 seconds 1
• Avoid excessive ventilation which increases intrathoracic pressure and decreases cardiac output 3

Compression-to-Ventilation Ratio

• 30 compressions to 2 breaths until an advanced airway is placed 1, 2
• Once advanced airway secured: continuous compressions with 1 breath every 6 seconds (10 breaths/minute) 1, 3, 2
• Change compressor every 2 minutes or sooner if fatigued 1

Rhythm Assessment and Defibrillation

Check rhythm every 2 minutes during CPR cycles. 1

For Shockable Rhythms (VF/Pulseless VT):

• Deliver one shock immediately (biphasic: manufacturer recommendation, typically 120-200J initial dose) 1
• Resume CPR immediately for 2 minutes starting with chest compressions—do not pause to check rhythm or pulse 1
• Charge defibrillator during compressions when possible to minimize interruption 1
• Repeat rhythm check after 2 minutes of CPR 1

For Non-Shockable Rhythms (Asystole/PEA):

• Continue high-quality CPR for 2-minute cycles 1
• Focus on identifying and treating reversible causes (H's and T's) 3
• Reassess rhythm every 2 minutes 1

Medication Administration

Establish IV/IO access as soon as possible without interrupting chest compressions. 1, 3, 2

Epinephrine:

• 1 mg IV/IO every 3-5 minutes throughout the resuscitation 1, 3, 2
• Administer during chest compressions, not during rhythm checks 1
• For non-shockable rhythms: give as soon as access obtained 1
• For shockable rhythms: give after second shock 1

Antiarrhythmics for Refractory VF/pVT:

• Amiodarone 300 mg IV/IO bolus after third shock, may repeat 150 mg once 1, 2
• Lidocaine 1-1.5 mg/kg IV/IO as alternative if amiodarone unavailable 1, 2

Atropine:

• No longer recommended for routine use in PEA/asystole per 2010 guidelines 1, 4

Advanced Airway Management

Secure advanced airway when feasible without prolonged interruption of compressions. 3

• Confirm placement with continuous waveform capnography—this is the gold standard 1, 3
• Once placed: deliver 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions 1, 3
• Use 100% oxygen during CPR to optimize arterial oxyhemoglobin content 1

Physiologic Monitoring During CPR

Utilize quantitative waveform capnography to monitor CPR quality and detect ROSC. 1, 3

• ETCO2 <10 mmHg suggests inadequate chest compressions—improve CPR quality 1
• Abrupt sustained increase in ETCO2 (typically >40 mmHg) indicates ROSC 3
• Monitor for spontaneous arterial pressure waves if intra-arterial line present 3

Reversible Causes: The H's and T's

Systematically evaluate and treat during resuscitation: 3

• Hypovolemia: IV fluid boluses 3
• Hypoxia: Ensure adequate oxygenation and ventilation 3
• Hydrogen ion (acidosis): Adequate ventilation 3
• Hypo/hyperkalemia: Check and correct electrolytes 3
• Hypothermia: Rewarm if accidental 3
• Tension pneumothorax: Needle decompression 3
• Tamponade (cardiac): Pericardiocentesis 3
• Toxins: Specific antidotes (e.g., naloxone for opioid overdose) 3, 2
• Thrombosis (pulmonary): Consider thrombolytics 3
• Thrombosis (coronary): Prepare for emergent cardiac catheterization 3

Post-Cardiac Arrest Care (After ROSC)

Confirm ROSC by checking pulse, blood pressure, and observing sustained increase in ETCO2. 3

Immediate Priorities:

• Maintain adequate perfusion with vasopressors as needed 3
• Titrate oxygen to SpO2 94-98% to avoid hyperoxemia 3
• Maintain normocapnia by adjusting ventilation 3
• Obtain 12-lead ECG immediately to identify STEMI 3
• Consider emergent coronary angiography for suspected cardiac etiology, especially with ST-elevation 3
• Initiate targeted temperature management for patients not following commands 3
• Monitor and treat seizures which are common post-arrest 3

Critical Pitfalls to Avoid

• Excessive pauses in compressions: Every second without compressions reduces survival—limit interruptions to <10 seconds 1, 2
• Inadequate compression depth or rate: Compressions must be hard and fast to generate adequate perfusion 1, 2
• Hyperventilation: Excessive ventilation decreases venous return and cardiac output 3, 2
• Prolonged pulse checks: If pulse not definitively felt within 10 seconds, resume compressions 1
• Incomplete chest recoil: Lean completely off chest between compressions 2
• Delayed defibrillation: Apply AED/defibrillator as soon as available 1