What are the standard Advanced Cardiovascular Life Support (ACLS) drug dosages and protocols?

Standard ACLS Drug Dosages and Protocols

Follow the 2020 American Heart Association ACLS guidelines for adult cardiac arrest, which provide specific drug dosages: epinephrine 1 mg IV/IO every 3-5 minutes for all rhythms, and for refractory VF/pVT, amiodarone 300 mg first dose followed by 150 mg second dose, or alternatively lidocaine 1-1.5 mg/kg first dose followed by 0.5-0.75 mg/kg second dose. 1

Core CPR Quality Metrics

High-quality CPR forms the foundation of all ACLS interventions 1:

• Compression depth: Push hard, at least 2 inches (5 cm) 1
• Compression rate: 100-120 compressions per minute 1
• Complete chest recoil between compressions 1
• Minimize interruptions in chest compressions 1
• Avoid excessive ventilation 1
• Rotate compressors every 2 minutes or sooner if fatigued 1

Defibrillation Energy

For shockable rhythms (VF/pulseless VT), deliver shocks immediately followed by 2 minutes of CPR 1:

• Biphasic defibrillators: Use manufacturer recommendation (typically 120-200 Joules initial dose); if unknown, use maximum available 1
• Subsequent shocks: Should be equivalent or higher doses 1
• Monophasic defibrillators: 360 Joules 1

Vasopressor Therapy

Epinephrine Dosing

Administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms (shockable and non-shockable) 1. This standard dose may be reasonable despite uncertainty about long-term neurological outcomes, as it improves short-term outcomes including ROSC and hospital admission 1.

Critical timing consideration: The evidence shows no survival benefit and potential harm from high-dose epinephrine (>1 mg doses), particularly in asphyxial arrest 1. Research demonstrates that higher cumulative epinephrine doses correlate with impaired oxygen delivery and consumption in the post-resuscitation period 2.

Vasopressin

Do not use vasopressin in combination with epinephrine as it offers no advantage over standard-dose epinephrine alone 1. This represents a change from earlier protocols that included vasopressin.

Antiarrhythmic Therapy for Refractory VF/pVT

Administer antiarrhythmics after defibrillation attempts for persistent or recurrent VF/pulseless VT 1:

Amiodarone (First-Line Option)

• First dose: 300 mg IV/IO bolus 1, 3
• Second dose: 150 mg IV/IO 1, 3
• May repeat for refractory VF/pVT 1

Lidocaine (Alternative Option)

• First dose: 1-1.5 mg/kg IV/IO 1
• Second dose: 0.5-0.75 mg/kg IV/IO 1

Important caveat: Neither amiodarone nor lidocaine has been shown to improve long-term survival or neurological outcomes 1. The 2018 AHA Focused Update notes that either drug is acceptable, with amiodarone previously favored but now considered equivalent to lidocaine 1. The recommendation is based primarily on potential benefits in short-term outcomes like ROSC 1.

Advanced Airway Management

Once an advanced airway is placed 1:

• Use endotracheal intubation or supraglottic advanced airway 1
• Confirm placement with waveform capnography or capnometry 1
• Deliver 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions 1
• No pause for ventilation once advanced airway is secured 1

Before advanced airway placement, use 30:2 compression-ventilation ratio for single rescuer or 15:2 for two rescuers in pediatric arrests 1.

Recognition of ROSC

Stop CPR and assess when any of these occur 1:

• Palpable pulse and blood pressure return 1
• Abrupt sustained increase in PETCO₂ (typically ≥40 mmHg) 1
• Spontaneous arterial pressure waves with intra-arterial monitoring 1

Reversible Causes (H's and T's)

Search for and treat these potentially reversible causes throughout resuscitation 1:

H's:

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

T's:

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

Atropine - No Longer Recommended

Atropine is no longer recommended for routine use in cardiac arrest 4. While the FDA label indicates a dose of 1 mg every 3-5 minutes for bradyasystolic cardiac arrest 4, this has been removed from current AHA ACLS algorithms 1. The 2020 guidelines do not include atropine in the cardiac arrest algorithm 1.

Algorithm Sequence

The circular ACLS algorithm emphasizes continuous cycles 1:

1. Check rhythm every 2 minutes 1
2. If VF/pVT: Shock → immediate CPR for 2 minutes → rhythm check 1
3. If asystole/PEA: CPR for 2 minutes → rhythm check 1
4. Establish IV/IO access as soon as feasible 1
5. Give epinephrine every 3-5 minutes throughout 1
6. Consider antiarrhythmics for refractory VF/pVT after initial shocks 1

Critical pitfall: The optimal sequence and timing of drug administration relative to shock delivery remains unknown 1. The current algorithm will be affected by the number of providers, their skill levels, and ability to secure vascular access 1. Prioritize minimizing interruptions in chest compressions over medication administration 1.