What is the management protocol for ACLS (Advanced Cardiovascular Life Support) rhythms?

ACLS Rhythm Management Protocol

High-quality CPR with minimal interruptions and early defibrillation for shockable rhythms are the only interventions proven to increase survival to hospital discharge—all other ACLS interventions should support, not delay, these priorities. 1, 2

Foundation: Four Cardiac Arrest Rhythms

ACLS addresses four distinct rhythms 1:

• Ventricular Fibrillation (VF): Disorganized electrical activity
• Pulseless Ventricular Tachycardia (pVT): Organized electrical activity without perfusion
• Pulseless Electrical Activity (PEA): Organized rhythm without mechanical activity
• Asystole: Absence of ventricular electrical activity

Immediate Actions (First 10 Seconds)

• Check responsiveness, breathing, and pulse simultaneously within 10 seconds 2
• Activate emergency response immediately 2
• Attach monitor/defibrillator pads as soon as available 2
• Start CPR immediately if no pulse is found 2

High-Quality CPR Parameters (Universal to All Rhythms)

Compression technique 1, 2:

• Depth: At least 2 inches (5 cm)
• Rate: 100-120 compressions/minute
• Complete chest recoil between compressions
• Minimize interruptions: All pauses <10 seconds
• Rotate compressors every 2 minutes to prevent fatigue

Ventilation strategy 1, 2:

• Before advanced airway: 30 compressions to 2 ventilations
• After advanced airway: Continuous compressions with 1 breath every 6 seconds (10 breaths/minute)
• Avoid excessive ventilation

Shockable Rhythms: VF/Pulseless VT

This is the only rhythm-specific therapy proven to increase survival to hospital discharge 1

Defibrillation Protocol 1, 2, 3:

1. Deliver shock immediately when defibrillator available—do not delay for medications
2. Energy settings:
   • Biphasic: 120-200J (manufacturer recommendation)
   • Monophasic: 360J
3. Resume CPR immediately after shock for 2 minutes before rhythm reassessment
4. Minimize "hands-off interval": Charge defibrillator during CPR, clear patient, shock, immediately resume compressions

Medication Protocol for Shock-Refractory VF/pVT 2, 3:

Epinephrine 2:

• 1 mg IV/IO every 3-5 minutes throughout arrest

Antiarrhythmics (after 2-3 shocks) 2, 3:

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

Non-Shockable Rhythms: PEA/Asystole

Focus on identifying and treating reversible causes while maintaining high-quality CPR 1

Medication Protocol 2:

• Epinephrine: 1 mg IV/IO every 3-5 minutes

Critical: The H's and T's (Reversible Causes) 1:

H's:

• Hypovolemia: Fluid resuscitation
• Hypoxia: Ensure adequate oxygenation/ventilation
• Hydrogen ion (acidosis): Address underlying cause
• Hypo-/hyperkalemia: Check and correct electrolytes
• Hypothermia: Rewarm patient

T's:

• Tension pneumothorax: Needle decompression
• Tamponade, cardiac: Pericardiocentesis
• Toxins: Specific antidotes
• Thrombosis, pulmonary: Consider thrombolytics
• Thrombosis, coronary: Consider PCI

Advanced Airway Management

Placement should not interrupt CPR for >10 seconds 1

Options 1, 2:

• Supraglottic airway device
• Endotracheal intubation

Confirmation and monitoring 1, 2:

• Waveform capnography is mandatory to confirm placement and monitor CPR quality
• Target PETCO₂ >10 mmHg (if <10 mmHg, improve CPR quality)

CPR Quality Monitoring

Quantitative parameters 1, 2:

• PETCO₂: Target >10 mmHg
• Intra-arterial pressure (if available): Target relaxation phase (diastolic) pressure >20 mmHg
• If these targets not met, immediately improve CPR quality

Return of Spontaneous Circulation (ROSC) Recognition 1:

• Pulse and blood pressure present
• Abrupt sustained increase in PETCO₂ (typically ≥40 mmHg)
• Spontaneous arterial pressure waves on monitoring

Special Circumstances

Pregnant patients 2:

• Perform lateral uterine displacement to relieve aortocaval compression

Hypothermic patients 1:

• Continue resuscitation until patient is rewarmed

Post-cardiac surgery patients 4:

• Address reversible causes FIRST before external compressions
• Consider up to 3 stacked shocks for VF/pVT
• Bedside echocardiography to identify tamponade/hypovolemia
• Consider ECPR if conventional CPR failing

Post-ROSC Care 2:

• Maintain oxygenation (avoid hypoxia and hyperoxia)
• Maintain hemodynamic stability
• Consider emergent coronary angiography for ST-elevation or ongoing ischemia
• Initiate targeted temperature management if patient doesn't follow commands

Critical Pitfalls to Avoid

• Never delay defibrillation for medication administration in VF/pVT 2, 3
• Do not perform prolonged pulse checks: If pulse not definitely felt within 10 seconds, resume CPR 3
• Avoid excessive ventilation after advanced airway placement 1, 3
• Do not interrupt compressions for advanced airway placement beyond 10 seconds 3
• Do not rely solely on ETCO₂ for termination decisions 3