From the Guidelines
The ACLS algorithm for managing cardiac arrest prioritizes high-quality CPR, defibrillation for shockable rhythms, and administration of epinephrine and antiarrhythmic drugs like amiodarone or lidocaine for persistent VF/VT, as recommended in the 2018 American Heart Association guidelines update 1. The algorithm begins with basic life support measures, including high-quality CPR with minimal interruptions, delivering 30 compressions followed by 2 breaths at a rate of 100-120 compressions per minute.
- The sequence of interventions is crucial, with defibrillation administered immediately for shockable rhythms, followed by epinephrine 1mg IV/IO every 3-5 minutes and consideration of either amiodarone or lidocaine for shock-refractory VF/pVT, as noted in the 2018 guidelines update 1.
- For non-shockable rhythms, epinephrine 1mg IV/IO is given immediately and repeated every 3-5 minutes.
- Throughout resuscitation, providers should identify and treat reversible causes using the "H's and T's" framework, which includes hypoxia, hypovolemia, hydrogen ion/acidosis, hypo/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis-pulmonary, and thrombosis-coronary.
- The algorithm emphasizes continuous reassessment of rhythm, pulse checks after rhythm analysis, and consideration of advanced airway placement without interrupting chest compressions, as highlighted in the 2015 American Heart Association guidelines update 2. Key considerations in the ACLS algorithm include:
- Establishing vascular access to enable drug administration without compromising the quality of CPR or timely defibrillation
- The optimal sequence of ACLS interventions, including administration of antiarrhythmic drugs during resuscitation and the preferred manner and timing of drug administration in relation to shock delivery, which is not yet fully understood, as noted in the 2015 guidelines update 2.
From the Research
ACLS Agorhythm
- The American Heart Association's Advanced Cardiovascular Life Support (ACLS) guidelines emphasize the importance of timely and effective management of cardiac arrest rhythms, including ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) 3, 4.
- Studies have shown that the development of secondary VF or VT during cardiac arrest is associated with increased mortality and more frequent administration of epinephrine 3.
- The effects of adrenaline on rhythm transitions in out-of-hospital cardiac arrest have been studied, with results showing that patients who received adrenaline had more rhythm transitions from return of spontaneous circulation (ROSC) and non-shockable rhythms to VF/VT 4.
- Key findings from these studies include: + More frequent administration of epinephrine during cardiac arrest is associated with development of secondary VF or VT 3. + Patients who received adrenaline had a higher proportion of VF/VT episodes after temporary ROSC 4. + Adrenaline administration was associated with more fibrillations from asystole or pulseless electrical activity, shock-resistant VF/VT, and rhythm transitions per patient 4.