What are the immediate steps for a patient requiring Advanced Cardiovascular Life Support (ACLS)?

Advanced Cardiovascular Life Support (ACLS): Immediate Steps

For any patient requiring ACLS, immediately initiate 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 deliver early defibrillation for shockable rhythms. 1

Initial Assessment and Activation

• Check responsiveness by tapping the patient's shoulder and shouting "Are you all right?" 1
• Simultaneously assess breathing and pulse within 10 seconds—look for no breathing or only gasping while checking for a definite pulse 2, 1
• Immediately activate the emergency response system if the patient is unresponsive with no breathing or only gasping 2, 1
• Retrieve the AED and emergency equipment or send someone to do so 2

High-Quality CPR Technique

Chest Compressions:

• Compression rate: 100-120/min 2, 1
• Compression depth: At least 2 inches (5 cm) 2, 1
• Allow complete chest recoil after each compression 2, 1
• Minimize interruptions to less than 10 seconds 2, 1
• Change compressor every 2 minutes or sooner if fatigued to maintain quality 2, 1

Ventilation:

• Perform cycles of 30 compressions to 2 breaths until an advanced airway is placed 2, 1
• Avoid excessive ventilation—this is a common pitfall that can impede venous return 3

Rhythm Assessment and Defibrillation

• Check rhythm as soon as the defibrillator/monitor is available 2
• For VF/pulseless VT: Deliver 1 shock immediately 2, 1
  • Biphasic: Use manufacturer recommendation (typically 120-200 Joules); if unknown, use maximum available 2
  • Monophasic: 360 Joules 2
• Resume CPR immediately for 2 minutes after the shock without pausing to check rhythm 2, 1
• For non-shockable rhythms (asystole/PEA): Resume CPR immediately for 2 minutes 2

Vascular Access and Medications

• Establish IV or IO access during CPR without interrupting compressions 2, 1
• Administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms 2, 1
• For shock-refractory VF/pVT (after 2-3 shocks):
  • Amiodarone: First dose 300 mg IV bolus, second dose 150 mg 2, 1
  • Alternative: Lidocaine: First dose 1-1.5 mg/kg, second dose 0.5-0.75 mg/kg 2, 1

Advanced Airway Management

• Place endotracheal tube or supraglottic airway when feasible without prolonged interruption of compressions 1
• Confirm placement with waveform capnography—ETCO₂ <10 mmHg suggests inadequate CPR quality 1, 3
• Once advanced airway is placed: Provide continuous chest compressions with 1 breath every 6 seconds (10 breaths/min) 2, 1
• Use HEPA filters on all ventilation devices, particularly important for suspected COVID-19 patients 2

CPR Quality Monitoring

• Monitor quantitative waveform capnography with target PETCO₂ >10 mmHg indicating adequate CPR 1, 3
• Consider intra-arterial pressure monitoring if available, with target relaxation phase pressure >20 mmHg 3
• Continuously assess: compression rate, depth, complete recoil, and minimal interruptions 3

Post-ROSC (Return of Spontaneous Circulation) Care

• Maintain adequate oxygenation: Target SpO₂ 94-98% to avoid both hypoxemia and hyperoxemia 1
• Maintain normocapnia by adjusting ventilation 1
• Support hemodynamics: Maintain MAP ≥65 mmHg with vasopressors as needed 4, 1
• Obtain 12-lead ECG immediately to identify ST-elevation MI 1
• Consider urgent coronary angiography for suspected cardiac etiology 1
• Initiate targeted temperature management for all patients who don't follow commands after ROSC 1

Critical Pitfalls to Avoid

• Do not delay defibrillation while preparing medications or establishing access 3
• Do not perform prolonged pulse checks—if pulse is not definitely felt within 10 seconds, resume CPR 3
• Do not hyperventilate—maintain 8-10 breaths/minute with advanced airway 3
• Do not interrupt compressions for extended periods during advanced airway placement 3

Special Considerations

For pregnant patients: Provide lateral uterine displacement to relieve aortocaval compression 3

For post-cardiac surgery patients: Consider immediate defibrillation for VF/VT before external compressions, and prepare for potential emergency resternotomy if standard measures fail within 5 minutes 2

For COVID-19 suspected/confirmed patients: Ensure appropriate PPE for aerosol-generating procedures (N95 respirator, gown, gloves, eye protection) and HEPA filters on all ventilation equipment 2