What are the latest Advanced Life Support (ALS) and Basic Life Support (BLS) protocols for emergency care in adult patients?

Latest BLS and ALS Protocols for Adult Cardiac Arrest

Follow the American Heart Association's streamlined approach: verify scene safety, immediately start high-quality chest compressions if no pulse is detected, apply the AED as soon as available, and minimize interruptions in compressions—this is the foundation that saves lives. 1, 2

Basic Life Support (BLS) Protocol

Initial Response Sequence

Scene safety comes first—never approach until you confirm it's safe. 1, 2

• Check responsiveness by shouting and tapping the victim 1, 2
• Activate emergency response system immediately via mobile device (allows you to stay with the victim) 1
• Retrieve or send someone for an AED and emergency equipment 1, 2
• Simultaneously assess breathing and pulse within 10 seconds maximum—look for absent or gasping respirations while checking carotid pulse 1, 2, 3

CPR Technique Specifications

Chest compressions must be 5-6 cm (at least 2 inches) deep at a rate of 100-120 compressions per minute—inadequate depth or rate renders CPR ineffective. 2, 3

• Use 30:2 compression-to-ventilation ratio (30 compressions, then 2 breaths) 1, 2, 3
• Allow complete chest recoil between compressions—leaning on the chest prevents cardiac refilling and is a critical error 2, 3
• Minimize interruptions in compressions to less than 10 seconds 1
• For untrained rescuers, compression-only CPR is acceptable and preferred over no CPR 2

Rescue Breathing Protocol

If pulse present but no normal breathing (respiratory arrest only), provide 1 breath every 5-6 seconds (10-12 breaths/minute). 1

• Check pulse every 2 minutes during rescue breathing 1
• If pulse disappears, immediately begin full CPR 1

AED Application

Apply the AED immediately when it arrives—do not delay CPR to retrieve it, but use it the moment it's available. 1, 2

• Check rhythm when prompted 1, 2
• Shockable rhythm (VF/pVT): Deliver 1 shock, immediately resume CPR for 2 minutes, then recheck rhythm 1, 2, 3
• Non-shockable rhythm (PEA/asystole): Resume CPR immediately for 2 minutes, then recheck rhythm 1, 3
• Continue until ALS providers arrive or victim shows signs of life 1

Special Consideration: Opioid Overdose

For suspected opioid overdose with pulse but no breathing, administer intranasal or intramuscular naloxone while providing standard BLS care. 1

• For cardiac arrest with suspected opioid involvement, consider naloxone after initiating CPR (Class IIb recommendation) 1

Advanced Life Support (ALS) Protocol

High-Quality CPR Foundation

ALS interventions are worthless without excellent CPR—maintain compression quality as the absolute priority. 1, 3

• Continue 100-120 compressions/minute at 5-6 cm depth 3
• Change compressors every 2 minutes or sooner if fatigued 3
• Use quantitative waveform capnography to monitor CPR quality if available 3

Rhythm Assessment and Defibrillation

Check rhythm every 2 minutes with minimal pause in compressions. 1, 3

• For VF/pVT: Deliver single shock with biphasic 120-200J (or monophasic 360J), immediately resume CPR for 2 minutes 1, 3
• If first shock fails and defibrillator capable, increase energy for subsequent shocks 1
• For PEA/asystole: Continue CPR without shock, reassess rhythm every 2 minutes 3

Medication Administration

Establish IV/IO access during ongoing CPR—do not interrupt compressions for vascular access. 3

Vasopressors

• Epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms 1, 3, 4
• No benefit from high-dose epinephrine over standard dosing 1, 5
• Vasopressin offers no advantage over epinephrine 1

Antiarrhythmics (for refractory VF/pVT)

• Amiodarone 300 mg IV/IO or Lidocaine 1-1.5 mg/kg IV/IO after initial shock failure 1, 3

Airway Management

There is equipoise between bag-mask ventilation and advanced airway—choose based on provider skill and clinical context. 1

• Consider endotracheal intubation or supraglottic airway 1, 3
• Confirm placement with continuous waveform capnography—this is mandatory, not optional 1, 3
• Once advanced airway placed: provide continuous compressions without pauses, give 1 breath every 6 seconds (10 breaths/minute) asynchronously 3
• Use highest possible inspired oxygen concentration during CPR 1

Physiological Monitoring

Waveform capnography serves multiple critical functions during ALS. 1, 3

• Confirms and continuously monitors tracheal tube position 1
• Monitors CPR quality 3
• May predict outcome (persistently low ETCO₂ suggests poor prognosis) 1

Reversible Causes: The H's and T's

Systematically evaluate and treat reversible causes—failure to identify these means failure to save the patient. 3, 5

• Hypovolemia: IV fluid boluses 5
• Hypoxia: Ensure adequate oxygenation and ventilation 5
• Hydrogen ion (acidosis): Adequate ventilation 5
• Hypo/hyperkalemia: Check and correct electrolytes 5
• Hypothermia: Rewarm if accidental 5
• Tension pneumothorax: Needle decompression 5
• Tamponade (cardiac): Pericardiocentesis 5
• Toxins: Specific antidotes (e.g., naloxone for opioids) 1, 5
• Thrombosis (pulmonary): Consider thrombolytics 1, 5
• Thrombosis (coronary): Urgent catheterization if indicated 5

Post-Resuscitation Care (After ROSC)

Immediate Stabilization

Confirm ROSC by checking pulse, blood pressure, or observing abrupt sustained increase in ETCO₂. 5

• Secure airway if not already done 5
• Provide 1 breath every 6 seconds (10 breaths/minute) 5
• Titrate oxygen to maintain SpO₂ 94-98%—avoid both hypoxemia and hyperoxemia 5
• Maintain normocapnia by monitoring waveform capnography 5

Hemodynamic Management

Administer vasopressors to maintain adequate blood pressure and tissue perfusion. 5

• Epinephrine remains primary vasopressor post-arrest 5, 4
• Avoid excessive ventilation which decreases cardiac output 5

Critical Next Steps

• Obtain 12-lead ECG immediately to identify ST-elevation MI 5
• Consider urgent coronary angiography for suspected cardiac etiology 5
• Begin targeted temperature management for patients not following commands after ROSC 1, 5
• Monitor and treat seizures (common post-arrest) 5

Critical Pitfalls to Avoid

• Never delay CPR to obtain history—start compressions immediately 2
• Never perform prolonged pulse checks—if uncertain after 10 seconds, start CPR 2
• Never provide shallow or slow compressions—"hard and fast" is not optional 2
• Never lean on chest between compressions—this prevents cardiac refilling 2
• Never hyperventilate—this decreases cerebral blood flow and cardiac output 5