What are the primary recommendations for cardiac arrest management according to Advanced Cardiovascular Life Support (ACLS) guidelines?

ACLS Guidelines for Cardiac Arrest Management

Foundation: High-Quality CPR is Paramount

The cornerstone of successful cardiac arrest management is immediate, high-quality CPR with minimal interruptions, as this is one of only two interventions (along with defibrillation for VF/pVT) proven to increase survival to hospital discharge. 1, 2

Critical CPR Parameters

• Compression rate: 100-120/min (not ≥100/min as in older guidelines) 1, 3, 2
• Compression depth: At least 2 inches (5 cm) in adults 1, 3, 2
• Complete chest recoil: Allow full recoil after each compression to permit cardiac filling and maintain coronary perfusion pressure 1, 3, 2
• Minimize interruptions: Keep pauses <10 seconds; maintain chest compression fraction >80% 3, 2
• Avoid excessive ventilation: This significantly impairs venous return and cardiac output 1, 3
• Rotate compressors every 2 minutes (or sooner if fatigued) to prevent quality deterioration 1, 2

Compression-to-Ventilation Ratios

• Without advanced airway: 30 compressions to 2 breaths 1, 2
• With advanced airway: Continuous compressions at 100-120/min with 1 breath every 6 seconds (10 breaths/min) 1, 2

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Rhythm-Specific Management

VF/Pulseless VT (Shockable Rhythms)

Early defibrillation combined with high-quality CPR is the only proven intervention to increase survival to hospital discharge for VF/pVT. 1

Defibrillation Protocol

• Deliver 1 shock immediately when VF/pVT identified 2
• Biphasic: 120-200 J initially (manufacturer recommendation); if unknown, use maximum available 1
• Monophasic: 360 J 1
• Resume CPR immediately after shock delivery without rhythm or pulse check, beginning with chest compressions 1, 2
• Continue CPR for 2 minutes before next rhythm check 1, 2

Medication Management for Shock-Refractory VF/pVT

For VF/pVT persisting after initial defibrillation attempts, either amiodarone or lidocaine may be administered, with recent evidence suggesting lidocaine may have slight advantages for in-hospital arrests. 1, 4

• Amiodarone: 300 mg IV/IO bolus first dose; 150 mg second dose 1
• Lidocaine: 1-1.5 mg/kg IV/IO first dose; 0.5-0.75 mg/kg second dose 1
• Epinephrine: 1 mg IV/IO every 3-5 minutes throughout resuscitation 2, 5

Important caveat: No antiarrhythmic drug has been proven to increase long-term survival or favorable neurological outcomes; recommendations are based on improved short-term outcomes (ROSC, survival to admission) 1

PEA/Asystole (Non-Shockable Rhythms)

• Immediate high-quality CPR 1, 2
• Epinephrine 1 mg IV/IO every 3-5 minutes 2
• Aggressively search for and treat reversible causes (H's and T's) 1, 2

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Monitoring CPR Quality

Physiologic Parameters (Preferred When Available)

• ETCO₂ (end-tidal CO₂): If <10 mmHg, attempt to improve CPR quality; ROSC typically associated with abrupt sustained increase to ≥40 mmHg 1, 2
• Intra-arterial pressure: If diastolic pressure <20 mmHg during relaxation phase, improve CPR quality 1
• Central venous oxygen saturation (ScvO₂): Can guide CPR quality 1

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Advanced Airway Management

Airway placement should not interrupt high-quality chest compressions; delay if necessary to maintain compression continuity. 2

• Options: Endotracheal intubation or supraglottic advanced airway 1, 2
• Confirmation: Use waveform capnography or capnometry to confirm and continuously monitor ET tube placement 1, 2
• Post-placement ventilation: 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions 1, 2

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Reversible Causes: The H's and T's

Systematically evaluate and treat reversible causes throughout the resuscitation. 1, 2

The H's

• Hypovolemia 1
• Hypoxia 1
• Hydrogen ion (acidosis) 1
• Hypo-/hyperkalemia 1
• Hypothermia 1

The T's

• Tension pneumothorax 1
• Tamponade, cardiac 1
• Toxins 1
• Thrombosis, pulmonary 1
• Thrombosis, coronary 1

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Post-ROSC Care

Immediate post-resuscitation management is critical for optimizing neurological outcomes. 2

Oxygenation and Ventilation

• Target SpO₂ 94-98% (avoid both hypoxemia and hyperoxemia) 2
• Maintain normocapnia by adjusting ventilation 2

Hemodynamic Support

• Maintain MAP ≥65 mmHg with vasopressors as needed 2

Cardiac Evaluation

• Obtain 12-lead ECG immediately to identify ST-elevation MI 2
• Consider urgent coronary angiography for suspected cardiac etiology 2

Neuroprotection

• Initiate targeted temperature management for all patients who don't follow commands after ROSC 2

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Key Algorithmic Sequence

1. Recognize cardiac arrest → Activate emergency response 2
2. Start high-quality CPR immediately (compressions first) 1, 3, 2
3. Attach monitor/defibrillator 2
4. Check rhythm every 2 minutes 1, 2
5. If VF/pVT: Shock → immediate CPR × 2 min → repeat 1, 2
6. If PEA/asystole: CPR × 2 min → reassess 1, 2
7. Establish IV/IO access during CPR 2
8. Administer epinephrine every 3-5 minutes 2
9. Consider antiarrhythmic (amiodarone or lidocaine) for shock-refractory VF/pVT 1
10. Search for reversible causes throughout 1, 2

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Common Pitfalls to Avoid

• Excessive interruptions in compressions: Even brief pauses significantly reduce coronary perfusion pressure and survival 1, 3
• Hyperventilation: Causes increased intrathoracic pressure, decreased venous return, and reduced cardiac output 1, 3
• Inadequate compression depth or rate: Compressions <5 cm or <100/min significantly reduce ROSC 3
• Delayed defibrillation: Every minute of delay in defibrillation for VF reduces survival by 7-10% 3
• Prolonged pulse checks: Should take <10 seconds; if uncertain, resume compressions 1, 2
• Failure to rotate compressors: Fatigue develops rapidly, degrading compression quality 1, 3