ACLS Documentation for Cardiac Arrest
An ACLS note for cardiac arrest must document the timeline of interventions, rhythm assessments, medications administered with doses and times, CPR quality metrics, airway management details, and patient response including ROSC indicators.
Essential Documentation Elements
Initial Assessment and Presentation
- Time of arrest discovery and initial rhythm (VF, pVT, PEA, or asystole) 1
- Witnessed vs. unwitnessed arrest with exact time if known 2
- Bystander CPR status prior to arrival 1
- Initial vital signs assessment including absence of pulse and respirations 1
CPR Quality Metrics
Document specific parameters throughout the resuscitation 1:
- Compression depth (at least 2 inches/5 cm) 1
- Compression rate (100-120/min) 1
- Compression-to-ventilation ratio (30:2 before advanced airway, continuous compressions after) 1
- Compressor rotation times (every 2 minutes or when fatigued) 1
- Duration of any interruptions in compressions 1
Physiologic Monitoring Parameters
- ETCO₂ values throughout resuscitation (target >10 mmHg during CPR, typically ≥40 mmHg with ROSC) 2, 1
- Intra-arterial pressure if available (diastolic >20 mmHg during CPR indicates adequate quality) 2
- Arterial blood pressure when ROSC achieved 2, 1
Rhythm Assessments
- Time of each rhythm check (every 2 minutes) 1
- Specific rhythm identified at each check 1
- Any rhythm changes during resuscitation 1
Defibrillation Details (for VF/pVT)
- Energy level delivered for each shock (biphasic: 120-200 J initially, monophasic: 360 J) 1
- Exact time of each defibrillation 1
- Number of shocks delivered before and after medications 1
- Patient response to each shock 1
Medication Administration
Document with precise timing 1:
Epinephrine:
Antiarrhythmics for shock-refractory VF/pVT:
- Amiodarone: 300 mg bolus first dose, 150 mg second dose 2, 1
- Lidocaine: 1-1.5 mg/kg first dose, 0.5-0.75 mg/kg second dose 2, 1
- Timing relative to shock delivery 2
Vascular Access
- Type of access (IV vs. IO) 1
- Location and time of access establishment 1
- Number of attempts if multiple 1
Airway Management
- Initial ventilation method (bag-mask with 30:2 ratio) 1
- Advanced airway type if placed (endotracheal tube vs. supraglottic device) 1
- Time of advanced airway placement 1
- Confirmation method (waveform capnography/capnometry mandatory) 1
- Ventilation rate after advanced airway (1 breath every 6 seconds = 10 breaths/min with continuous compressions) 1
- ETCO₂ values to confirm tube placement 1
Reversible Causes Assessment
Document evaluation for the H's and T's 1:
- Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia 1
- Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary) 1
Return of Spontaneous Circulation (ROSC)
- Exact time of ROSC 1
- Pulse presence and blood pressure 2, 1
- Abrupt sustained ETCO₂ increase (typically ≥40 mmHg) 2, 1
- Spontaneous arterial pressure waves if intra-arterial monitoring present 2, 1
Resuscitation Duration and Outcome
- Total duration of resuscitation 1
- Final outcome (ROSC achieved, ongoing resuscitation, or termination) 1
- Neurological status if ROSC achieved 2
- Post-cardiac arrest care initiated 1
Critical Documentation Pitfalls
Avoid vague timing: Every intervention requires precise time documentation, as adherence to ACLS timing guidelines (epinephrine every 3-5 minutes, rhythm checks every 2 minutes) correlates with improved outcomes 3.
Don't omit CPR quality metrics: Studies demonstrate that adherence to specific CPR quality parameters (depth, rate, minimizing interruptions) directly impacts ROSC and survival 3, 1.
Never skip ETCO₂ documentation: This is mandatory for confirming advanced airway placement and provides real-time feedback on CPR quality and early indication of ROSC 1, 4.
Document deviations from guidelines: Research shows that increased deviations from ACLS protocols correlate with decreased ROSC and survival rates 3.