What are the steps for providing advanced life support (ALS) to a patient with a life-threatening condition?

Advanced Life Support Protocol

Immediately begin high-quality CPR at 100-120 compressions per minute with a depth of at least 2 inches (5 cm), allowing complete chest recoil, while simultaneously activating the emergency response system and preparing for defibrillation. 1

Immediate Assessment and Initial Actions

Scene safety and rapid assessment are critical first steps:

• Ensure scene safety, then immediately assess responsiveness by shouting and shaking the patient 2, 1
• Check for breathing and pulse simultaneously within 10 seconds—do not exceed this time frame 3, 1
• If no pulse or only gasping respirations are present, immediately begin CPR without delay 1
• Activate the emergency response system and call for nearby help 1

If the patient has a pulse but is not breathing normally:

• Open the airway using head tilt-chin lift maneuver 2, 1
• Provide rescue breathing at 1 breath every 6 seconds (10 breaths per minute) 1
• Administer supplemental oxygen immediately to maintain oxygen saturation >95% 1
• Reassess pulse every 2 minutes 2

High-Quality CPR Technique

CPR quality directly impacts survival—execute these parameters precisely:

• Deliver 30 compressions followed by 2 breaths (30:2 ratio for single rescuer, 15:2 for two rescuers) 2, 1
• Push hard: minimum depth of 2 inches (5 cm) in adults 1
• Push fast: rate of 100-120 compressions per minute 1
• Allow complete chest recoil between each compression 1
• Minimize interruptions in chest compressions to less than 10 seconds 1
• Avoid excessive ventilation, which impairs venous return and cardiac output 1
• Rotate compressors every 2 minutes or sooner if fatigued 1

Defibrillation Strategy

For shockable rhythms (VF/pulseless VT):

• Apply the AED or manual defibrillator as soon as available 1
• Deliver one shock immediately upon rhythm confirmation 1
• Use biphasic waveform defibrillators when available 4
• If the first shock fails and the defibrillator is capable of higher energy, increase energy for subsequent shocks 4
• Resume CPR immediately after shock delivery for 2 minutes before rechecking rhythm 1

For non-shockable rhythms (PEA/Asystole):

• Resume CPR immediately for 2 minutes 1
• Focus on identifying and treating reversible causes (H's and T's) 1

Airway Management

There is equipoise between basic and advanced airway strategies—choose based on provider skill and clinical context:

• Bag-mask ventilation with oropharyngeal airway is acceptable and may be preferred if advanced airway placement causes prolonged interruptions in chest compressions 4
• If an advanced airway is placed (endotracheal tube or supraglottic airway), provide 1 breath every 6 seconds (10 breaths per minute) with continuous uninterrupted chest compressions 4, 1
• Use waveform capnography to confirm and continuously monitor endotracheal tube placement 4, 1
• Use the highest possible inspired oxygen concentration during CPR 4

Critical airway management principles:

• Avoid excessive ventilation, which increases intrathoracic pressure and impairs venous return 1
• Persistently low ETCO2 values (<10 mm Hg) during CPR indicate poor CPR quality or low likelihood of ROSC 1
• Do not use ETCO2 cutoff values alone to decide when to terminate resuscitation 4

Vascular Access and Medication Administration

Establish IV or IO access as soon as possible, but do not delay CPR:

• Obtain vascular access during ongoing CPR without interrupting compressions 1
• Administer epinephrine 1 mg IV/IO every 3-5 minutes during cardiac arrest 4, 1
• Standard-dose epinephrine (1 mg) is recommended based on observed benefit in short-term outcomes (ROSC and hospital admission), despite uncertainty about long-term neurologic outcomes 4

For refractory VF/pulseless VT:

• Administer amiodarone 300 mg IV/IO bolus, followed by 150 mg if VF/pVT persists 4
• Lidocaine is an alternative if amiodarone is unavailable 4
• These antiarrhythmic drugs improve rates of ROSC but have uncertain effects on long-term survival 4

Do not administer atropine during PEA or asystole—it has been removed from cardiac arrest algorithms due to lack of benefit 1

Physiological Monitoring During CPR

Continuous monitoring guides resuscitation quality and helps predict outcomes:

• Use waveform capnography to monitor CPR quality and detect ROSC 4
• An abrupt sustained increase in ETCO2 (typically ≥40 mm Hg) suggests ROSC 1
• If cardiac ultrasound can be performed without interfering with standard ACLS protocol, consider it as an additional diagnostic tool to identify potentially reversible causes 4
• Monitor for signs of ROSC including palpable pulse, measurable blood pressure, and spontaneous arterial pressure waves 1

Identifying and Treating Reversible Causes

During each 2-minute CPR cycle, systematically consider the H's and T's:

H's:

• Hypovolemia: administer IV fluids 1
• Hypoxia: ensure adequate oxygenation and ventilation 1
• Hydrogen ion (acidosis): optimize ventilation 1
• Hypo-/hyperkalemia: treat electrolyte abnormalities 1
• Hypothermia: initiate rewarming 1

T's:

• Tension pneumothorax: perform needle decompression 1
• Tamponade (cardiac): perform pericardiocentesis 1
• Toxins: administer specific antidotes (e.g., naloxone for opioid overdose) 3, 1
• Thrombosis (pulmonary): consider thrombolytics 1
• Thrombosis (coronary): consider emergent cardiac catheterization 1

Special Circumstances

For suspected opioid overdose:

• Standard resuscitation measures (CPR, airway management) take absolute priority over naloxone administration 4, 3, 1
• Administer naloxone via IV, IM, subcutaneous, IO, or intranasal routes for respiratory arrest associated with opioid toxicity 4, 3
• Repeat naloxone doses at 2-3 minute intervals if respiratory function does not improve 3

For cardiac arrest during pregnancy (second half of pregnancy):

• Perform perimortem cesarean delivery if ROSC is not achieved within 4 minutes 4

Post-Resuscitation Care

Once ROSC is achieved, immediately initiate post-cardiac arrest care:

• Avoid hypoxia: maintain oxygen saturation >94% 4
• Avoid hyperoxia: titrate FiO2 once arterial oxygen can be measured reliably 4
• Use 100% inspired oxygen until arterial oxygen saturation or partial pressure can be measured 4
• Maintain PaCO2 within normal physiological range (35-45 mm Hg) 4
• Target hemodynamic goals: maintain mean arterial pressure ≥65 mm Hg 4

Targeted Temperature Management (TTM):

• Select and maintain a constant target temperature between 32°C and 36°C for at least 24 hours 4
• Use TTM for adults with out-of-hospital cardiac arrest with initial shockable rhythm who remain unresponsive after ROSC 4
• Consider TTM for adults with out-of-hospital cardiac arrest with initial non-shockable rhythm who remain unresponsive after ROSC 4
• Consider TTM for adults with in-hospital cardiac arrest with any initial rhythm who remain unresponsive after ROSC 4
• Do not use prehospital cooling with rapid infusion of large volumes of cold IV fluid immediately after ROSC 4
• Prevent and treat fever in persistently comatose adults after completion of TTM 4

Seizure management:

• Do not use routine seizure prophylaxis in post-cardiac arrest patients 4
• Treat seizures if they occur 4

Glucose management:

• Do not modify standard glucose management protocols for adults with ROSC after cardiac arrest 4

Critical Pitfalls to Avoid

• Never delay CPR to establish vascular access or administer medications 1
• Never rely on clinical criteria alone before 72 hours after ROSC to estimate prognosis in patients treated with TTM 4
• Never use ETCO2 cutoff values alone as a mortality predictor or to decide when to stop resuscitation 4
• Never administer atropine during PEA or asystole 1
• Never allow excessive ventilation during CPR 1
• Never interrupt chest compressions for more than 10 seconds except for rhythm checks and shock delivery 1