What is the complete adult Advanced Cardiovascular Life Support (ACLS) management protocol, including medication names, doses, and steps for shockable rhythms, non‑shockable rhythms, bradyarrhythmias, and tachyarrhythmias?

Complete ACLS Management Protocol

For cardiac arrest, immediately begin high-quality CPR with compressions at 100-120/min and depth of at least 2 inches, minimize interruptions, and follow rhythm-specific protocols: defibrillate shockable rhythms (VF/pVT) with epinephrine 1 mg IV/IO every 3-5 minutes and amiodarone 300 mg IV/IO for shock-refractory cases; for non-shockable rhythms (PEA/asystole) give epinephrine 1 mg IV/IO every 3-5 minutes while treating reversible causes. 1, 2

High-Quality CPR Foundation

All ACLS interventions depend on excellent CPR quality 1:

• Push hard and fast: Compress at least 2 inches (5 cm) deep at a rate of 100-120 compressions/minute 1
• Allow complete chest recoil between compressions to maximize cardiac filling 1
• Minimize interruptions: Keep pauses in compressions as brief as possible (ideally <10 seconds) 1
• Avoid excessive ventilation: Over-ventilation impairs cardiac output 1
• Rotate compressors every 2 minutes or sooner if fatigued to maintain quality 1
• Without advanced airway: Use 30:2 compression-ventilation ratio 1
• With advanced airway: Provide continuous compressions with 1 breath every 6 seconds (10 breaths/min) 1

Shockable Rhythms (VF/Pulseless VT)

Immediate Actions

• Defibrillate immediately for witnessed arrest 1
• For unwitnessed arrest, provide 2 minutes of CPR before first shock 1
• Resume CPR immediately after shock delivery for 2 minutes before pulse check 1

Medication Protocol

Epinephrine: 1 mg IV/IO every 3-5 minutes throughout resuscitation 3, 1

Amiodarone (first-line antiarrhythmic for shock-refractory VF/pVT):

• First dose: 300 mg IV/IO bolus 3, 1
• Second dose: 150 mg IV/IO if VF/pVT persists 3

Lidocaine (alternative if amiodarone unavailable):

• First dose: 1-1.5 mg/kg IV/IO 3, 1
• Additional doses: 0.5-0.75 mg/kg IV/IO, maximum cumulative dose 3 mg/kg 3

Critical Considerations

• No antiarrhythmic has definitively improved long-term survival or neurological outcomes 1
• Focus remains on high-quality CPR and early defibrillation 1
• Prophylactic lidocaine may be considered post-resuscitation to prevent VF/pVT recurrence 1

Non-Shockable Rhythms (PEA/Asystole)

Immediate Actions

• Do NOT attempt defibrillation 3
• Focus on high-quality CPR and identifying reversible causes 1

Medication Protocol

Epinephrine: 1 mg IV/IO every 3-5 minutes—give as early as possible for non-shockable rhythms 1

Atropine (for PEA with rate <60/min or asystole):

• Dose: 1 mg IV/IO, may repeat every 3-5 minutes 3
• Maximum total dose: 3 mg 3

Reversible Causes (H's and T's)

Aggressively search for and treat 3:

• Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia
• Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (coronary/pulmonary)

Bradyarrhythmias

Unstable Bradycardia (with signs of shock, altered mental status, chest pain, acute heart failure)

Atropine:

• First-line: 1 mg IV bolus 3
• Repeat every 3-5 minutes as needed 3
• Maximum total dose: 3 mg 3

If atropine ineffective, consider:

• Transcutaneous pacing (immediate) 3
• Dopamine infusion: 5-20 mcg/kg/min IV 3
• Epinephrine infusion: 2-10 mcg/min IV 3

Glycopyrrolate (alternative anticholinergic): Dosing per institutional protocol 3

Stable Bradycardia

• Observe and monitor 3
• Prepare for transcutaneous pacing if deterioration occurs 3

Tachyarrhythmias

Critical First Step: Assess Stability

Unstable signs (requiring immediate cardioversion): acute altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or shock 2

Unstable Tachycardia (Any Type)

Synchronized cardioversion (immediate):

• Establish IV access if possible, but do not delay cardioversion 2
• Sedate if conscious (unless extremely unstable) 2
• Energy doses: Start with 100-200J for narrow-complex regular, 200J for atrial fibrillation, 100J for atrial flutter 3

Stable Narrow-Complex Regular Tachycardia (SVT)

Step 1: Vagal maneuvers (Valsalva, carotid massage if no bruits) 2

Step 2: Adenosine:

• First dose: 6 mg rapid IV push followed immediately by 20 mL saline flush 3, 2
• Second dose: 12 mg IV push if first dose ineffective 3, 2
• Third dose: 12 mg IV push if needed 3
• Have defibrillator ready: May precipitate rapid AF in WPW 2
• Reduce dose in cardiac transplant patients or with dipyridamole/carbamazepine 3

Step 3: If adenosine fails or SVT recurs:

Diltiazem:

• Initial: 15-20 mg (0.25 mg/kg) IV over 2 minutes 3
• Additional: 20-25 mg (0.35 mg/kg) IV in 15 minutes if needed 3
• Maintenance infusion: 5-15 mg/h 3

Verapamil (alternative):

• Initial: 2.5-5 mg IV over 2 minutes 3
• May repeat: 5-10 mg every 15-30 minutes to total 20-30 mg 3

Beta-blockers (metoprolol, esmolol, atenolol, propranolol): Per dosing tables 3

Stable Atrial Fibrillation/Flutter (Rate Control)

• Diltiazem or verapamil (doses above) 3, 2
• Beta-blockers 3
• Never use calcium channel blockers or beta-blockers in pre-excited AF (WPW) 2

Stable Wide-Complex Tachycardia

Assume ventricular tachycardia until proven otherwise 2

Amiodarone (first-line):

• Loading: 150 mg IV over 10 minutes 3
• May repeat 150 mg every 10 minutes as needed 3
• Maintenance infusion: 1 mg/min for 6 hours, then 0.5 mg/min 3

Procainamide (alternative):

• 20-50 mg/min IV until arrhythmia suppressed, hypotension, QRS widens >50%, or maximum 17 mg/kg given 3
• Maintenance infusion: 1-4 mg/min 3

Lidocaine (alternative):

• Initial: 1-1.5 mg/kg IV 3
• Additional: 0.5-0.75 mg/kg every 5-10 minutes, maximum 3 mg/kg 3
• Maintenance infusion: 1-4 mg/min 3

Vascular Access

• Attempt IV access first 1
• Use intraosseous (IO) access if IV unsuccessful or not feasible 1
• All ACLS medications can be given via IO route 1

Advanced Airway Management

• Do not interrupt compressions for prolonged periods during intubation 1
• Use endotracheal tube or supraglottic airway 1
• Confirm placement with waveform capnography 1
• PETCO₂ <10 mm Hg: Improve CPR quality 1
• PETCO₂ abrupt increase to ≥40 mm Hg: Suggests return of spontaneous circulation (ROSC) 1

Monitoring CPR Quality

• Quantitative waveform capnography: Monitor continuously 1
• Arterial diastolic pressure <20 mm Hg: Improve CPR quality 1
• Continuously assess compression rate, depth, and recoil 1

Critical Pitfalls to Avoid

• Never delay defibrillation in unstable patients to obtain 12-lead ECG 2
• Never give calcium channel blockers or beta-blockers for wide-complex tachycardia unless VT definitively ruled out 2
• Never treat sinus tachycardia with antiarrhythmics—identify and treat underlying cause 2
• Never assume narrow-complex tachycardia is benign—always assess hemodynamic stability first 2
• Never treat compensatory sinus tachycardia with rate-control agents—can precipitate cardiovascular collapse 2

Post-Cardiac Arrest Care

• Optimize oxygenation and ventilation 1
• Treat hypotension with fluids and vasopressors 1
• Consider targeted temperature management 1
• Identify and treat precipitating causes 1
• Transfer to appropriate level of care for post-resuscitation management 1