What are the complete ACLS interventions and management for cardiac arrest, including high‑quality chest compressions, defibrillation, medication dosing, airway management, treatment of reversible causes, and post‑cardiac‑arrest care?

Complete ACLS Intervention and Management for Cardiac Arrest

Immediate high-quality chest compressions at 100-120/min with depth of at least 2 inches (5 cm), early defibrillation for shockable rhythms, epinephrine 1 mg IV/IO every 3-5 minutes, and systematic treatment of reversible causes form the core of ACLS management, with post-cardiac arrest care including targeted temperature management being critical for neurologically intact survival. 1, 2

Initial Recognition and Response

Immediate Actions

• Recognize cardiac arrest by checking for unresponsiveness and absent or abnormal breathing (only gasping) 1
• Simultaneously activate emergency response system and begin CPR without delay 1
• Start chest compressions immediately without removing clothing first 1
• Retrieve defibrillator/AED as soon as available 1

High-Quality CPR Parameters

Compression Technique

• Depth: At least 2 inches (5 cm) in adults 1, 2
• Rate: 100-120 compressions per minute (optimal appears to be 121-140/min based on ROSC data, though guideline recommendation remains 100-120/min) 1, 3
• Allow complete chest recoil after each compression 1
• Minimize interruptions in compressions to less than 10 seconds 1
• Rotate compressors every 2 minutes or sooner if fatigued 1

Compression-Ventilation Ratio

• Without advanced airway: 30 compressions to 2 breaths 1
• With advanced airway: Continuous compressions without pauses, 1 breath every 6 seconds (10 breaths/min) 1
• Avoid excessive ventilation 1

CPR Quality Monitoring

• End-tidal CO2 (ETCO2): If PETCO2 <10 mm Hg, attempt to improve CPR quality 1
• Intra-arterial pressure: If diastolic pressure <20 mm Hg during relaxation phase, improve CPR quality 1
• Abrupt sustained increase in PETCO2 to ≥40 mm Hg suggests return of spontaneous circulation 1

Rhythm-Specific Management

Shockable Rhythms (VF/Pulseless VT)

Defibrillation Protocol

• Biphasic defibrillators: 120-200 J initial dose (manufacturer recommendation); if unknown, use maximum available 1, 2
• Subsequent shocks: Use at least equivalent energy, consider higher doses 1
• Monophasic defibrillators: 360 J 1
• Deliver shock and immediately resume CPR for 2 minutes without pulse/rhythm check 1

Medication Protocol for VF/Pulseless VT

• Epinephrine 1 mg IV/IO every 3-5 minutes starting after first defibrillation attempt 1, 2
• Amiodarone 300 mg IV/IO bolus for refractory VF/pVT after third shock 1, 2
• Second amiodarone dose: 150 mg IV/IO if VF/pVT persists 1
• Alternative to amiodarone: Lidocaine 1-1.5 mg/kg initial dose, then 0.5-0.75 mg/kg 1

Non-Shockable Rhythms (PEA/Asystole)

Management Protocol

• Immediate high-quality CPR 1
• Epinephrine 1 mg IV/IO every 3-5 minutes starting immediately (earlier administration associated with higher ROSC rates in non-shockable rhythms) 1, 2
• Aggressive search for reversible causes (H's and T's) 1, 4

Vascular Access and Medication Administration

Access Routes

• IV access is preferred route, but IO access is equally acceptable 2
• Never delay CPR or defibrillation to establish vascular access 2
• Endotracheal route is no longer emphasized in current guidelines 2

Advanced Airway Management

Airway Options

• Endotracheal intubation or supraglottic advanced airway 1
• Waveform capnography or capnometry to confirm and monitor ET tube placement 1
• Minimize interruptions in chest compressions during airway placement 1

Post-Airway Ventilation

• Deliver 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions 1
• Avoid excessive ventilation which can impair venous return 1

Reversible Causes (H's and T's)

The 4 H's

• Hypovolemia: Administer IV fluids, blood products as indicated 1, 4
• Hypoxia: Ensure adequate oxygenation and ventilation 1
• Hydrogen ion (acidosis): Consider sodium bicarbonate 1 mEq/kg for prolonged arrest, known hyperkalemia, or tricyclic overdose 2
• Hypo-/Hyperkalemia: Treat electrolyte abnormalities aggressively 1, 4
• Hypothermia: Rewarm appropriately 1

The 4 T's

• Tension pneumothorax: Needle decompression, chest tube 1, 4
• Tamponade (cardiac): Pericardiocentesis, consider point-of-care ultrasound for diagnosis 1, 4
• Toxins: Specific antidotes as indicated 1, 4
• Thrombosis (pulmonary): Consider thrombolytics for massive PE 1, 4
• Thrombosis (coronary): Early PCI for suspected MI 1

Recognition of ROSC

Clinical Signs

• Palpable pulse and measurable blood pressure 1
• Abrupt sustained increase in PETCO2 typically ≥40 mm Hg 1
• Spontaneous arterial pressure waves with intra-arterial monitoring 1

Post-Cardiac Arrest Care

Immediate Post-ROSC Management

• Targeted temperature management for all patients who do not follow commands after ROSC 1
• Early percutaneous coronary intervention for suspected cardiac etiology 1
• Comprehensive structured multidisciplinary approach to optimize outcomes 1
• Avoid premature withdrawal of care - accurate neurological prognostication is critical 1

Critical Pitfalls to Avoid

Common Errors

• Excessive ventilation impairs venous return and cardiac output 1
• Prolonged interruptions in chest compressions for rhythm checks, pulse checks, or procedures 1, 5
• Inadequate compression depth or rate compromises perfusion 1, 3
• Delayed defibrillation in shockable rhythms reduces survival 1
• Failure to systematically address reversible causes 4
• Compressor fatigue - rotate every 2 minutes without exception 1

Time-Critical Benchmarks

• Time to first compression: Should be <40 seconds from cardiac arrest recognition 6
• Time to defibrillation: Should be <3 minutes for witnessed VF arrest 1, 6
• Time to calling cardiac arrest team: Should be <2 minutes 6