What are the steps for Advanced Cardiovascular Life Support (ACLS) in cardiac arrest management?

Advanced Cardiovascular Life Support (ACLS) Protocol

Immediately begin high-quality CPR with chest compressions at 100-120/min and depth of at least 2 inches (5 cm), minimize interruptions to less than 10 seconds, and defibrillate shockable rhythms as soon as possible while administering epinephrine 1 mg IV/IO every 3-5 minutes throughout the resuscitation. 1, 2

Initial Assessment and Activation

• Check for responsiveness by tapping the victim's shoulder and shouting "Are you all right?" 1
• Simultaneously assess breathing and pulse within 10 seconds, looking for no breathing or only gasping while checking for a definite pulse 1
• Immediately activate the emergency response system if the patient is unresponsive with no breathing or only gasping 1, 2
• Retrieve an automated external defibrillator (AED) immediately 2

High-Quality CPR Technique

Chest compressions are the foundation of successful resuscitation and must be performed with precision:

• Push hard at a depth of at least 2 inches (5 cm) in adults 1, 2
• Maintain a compression rate of 100-120 per minute 1, 2
• Allow complete chest recoil after each compression without leaning on the chest 1, 2
• Minimize interruptions in compressions to less than 10 seconds 1, 2
• Perform cycles of 30 compressions to 2 breaths until an advanced airway is placed 1
• Change the compressor every 2 minutes or sooner if fatigued to maintain quality 1, 2

Rhythm Assessment and Defibrillation

For shockable rhythms (VF/pulseless VT):

• Deliver 1 shock immediately when VF/pVT is identified 1, 2
• Resume CPR immediately for 2 minutes after the shock without pausing to check rhythm 1, 2
• Do not delay defibrillation to establish IV access or administer medications 2
• Check the cardiac rhythm after every 2 minutes of CPR 2

Vascular Access and Medication Administration

Establish IV or IO access during CPR without interrupting compressions:

• Administer epinephrine 1 mg IV/IO every 3-5 minutes throughout the resuscitation for all cardiac arrest rhythms 1, 2
• For shock-refractory VF/pulseless VT, administer either amiodarone (300 mg IV/IO bolus) or lidocaine (1-1.5 mg/kg IV/IO) 1, 2

Important caveat: While both amiodarone and lidocaine are guideline-recommended, recent evidence suggests lidocaine may be associated with better outcomes for in-hospital cardiac arrest, showing higher rates of ROSC, 24-hour survival, survival to discharge, and favorable neurologic outcomes compared to amiodarone 3. However, both remain acceptable choices per current guidelines 1, 2.

Advanced Airway Management

• Place an endotracheal tube or supraglottic airway when feasible without prolonged interruption of compressions 1, 2
• Confirm placement immediately with waveform capnography, with ETCO₂ <10 mmHg suggesting inadequate CPR quality 1, 2
• Once advanced airway is secured, provide continuous chest compressions with 1 breath every 6 seconds (10 breaths/min) 1, 2
• Administer supplemental oxygen as soon as available 2
• Deliver each rescue breath over 1 second with sufficient volume to achieve visible chest rise 2
• Avoid excessive ventilation which increases intrathoracic pressure and decreases cardiac output 2

Reversible Causes (H's and T's)

Systematically evaluate and treat reversible causes throughout resuscitation:

• Hypovolemia - fluid resuscitation
• Hypoxia - oxygenation and ventilation
• Hydrogen ion (acidosis) - consider bicarbonate for severe acidosis
• Hypo/hyperkalemia - electrolyte correction
• Hypothermia - rewarming strategies
• Tension pneumothorax - needle decompression
• Tamponade (cardiac) - pericardiocentesis
• Toxins - antidotes as appropriate
• Thrombosis (pulmonary) - consider thrombolytics
• Thrombosis (coronary) - consider PCI 2

Post-ROSC Care

Once return of spontaneous circulation is achieved:

• Maintain adequate oxygenation, targeting SpO₂ 94-98% (previously 92-98%) to avoid both hypoxemia and hyperoxemia 1, 2
• Maintain normocapnia by adjusting ventilation 1
• Support hemodynamics, maintaining MAP ≥65 mmHg with vasopressors as needed 1, 2
• Obtain 12-lead ECG immediately to identify ST-elevation MI 1, 2
• Consider urgent coronary angiography for suspected cardiac etiology 1, 2
• Initiate targeted temperature management for all patients who don't follow commands after ROSC 1, 2
• Continue warming to a goal temperature of approximately 32-34°C for patients appropriate for induced hypothermia 1

Common Pitfalls to Avoid

• Inadequate compression depth or rate - Use feedback devices when available to ensure quality 1, 2
• Excessive interruptions - Keep pauses under 10 seconds, even for rhythm checks 1, 2
• Delayed defibrillation - Shock immediately when VF/pVT is identified 2
• Hyperventilation - Stick to 1 breath every 6 seconds with advanced airway 1, 2
• Premature termination - Continue resuscitation efforts until ROSC or clear termination criteria are met 1, 2