ACLS

• The arrest algorithm starts with CPR and includes giving oxygen, attaching a monitor/defibrillator, and considering advanced airway and capnography.
• Rhythm determines whether or not a shock is needed, and if so, what type of shock.
• Epinephrine is administered every 3-5 minutes, and the arrest algorithm includes considering an advanced airway and capnography.
• Amiodarone or lidocaine are used to treat reversible causes, and the arrest algorithm includes considering an advanced airway and capnography.
• If there are no signs of return of spontaneous circulation (ROSC), the arrest algorithm goes to 10 or 11.
• Post-cardiac arrest care includes considering the appropriateness of continued resuscitation.
• CPR quality is determined by pushing hard and fast and allowing complete chest recoil, minimizing interruptions in compressions, and avoiding excessive ventilation.
• Shock energy for defibrillation is biphasic, with a manufacturer recommendation of initial dose of 120-200 J, and if unknown, use maximum available.
• Drug therapy includes an IV/IO dose of epinephrine of 1 mg every 3-5 minutes, an Amiodarone IV/10 dose of 300 mg bolus and 150 mg, and a Lidocaine IV/IO dose of 1-1.5 mg/kg and 0.5-0.75 mg/kg.
• Advanced airway includes an endotracheal intubation or supraglottic advanced airway, waveform capnography or capnometry to confirm and monitor ET tube placement, and giving 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions.
• Return of spontaneous circulation (ROSC) is indicated by an abrupt sustained increase in PETCO, typically ≥40 mm Hg, and spontaneous arterial pressure waves with intra-arterial monitoring.
• Reversible causes of cardiac arrest include hypovolemia, hypoxia, hydrogen ion (acidosis), hyperkalemia, hypothermia, tension pneumothorax, tamponade, cardiac, and toxins.
• If there are no signs of return of spontaneous circulation (ROSC), go to steps 10 or 11.
• If there is return of spontaneous circulation (ROSC), go to Post-Cardiac Arrest Care.
• Consider the appropriateness of continued resuscitation.
• For ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), perform CPR by pushing hard (at least 2 inches [5 cm]) and fast (100-120/min) and allowing complete chest recoil.
• Minimize interruptions in compressions.
• Avoid excessive ventilation.
• Change the compressor every 2 minutes, or sooner if fatigued.
• If no advanced airway, use a compression-ventilation ratio of 30:2.
• Quantitative waveform capnography can be used to assess CPR quality, and if PETCO2 is low or decreasing, reassess CPR quality.
• For shock energy for defibrillation, use biphasic with a manufacturer recommendation of initial dose of 120-200 J, or if unknown, use maximum available.
• Second and subsequent doses of biphasic should be equivalent, and higher doses may be considered.
• For monophasic, use 360 J.
• For drug therapy, use epinephrine IV/IO dose of 1 mg every 3-5 minutes.
• Critical care management includes continuously monitoring core temperature (esophageal, rectal, bladder), maintaining normoxia, normocapnia, euglycemia, providing continuous or intermittent electroencephalogram (EEG) monitoring, and providing lung-protective ventilation.
• Consider possible hypoxic and toxicologic causes.
• Heart rate typically <50/min if bradyarrhythmia.
• Emergent cardiac intervention includes early evaluation of 12-lead electrocardiogram (ECG) and hemodynamics for decision on cardiac intervention.
• Post-cardiac arrest care includes managing and providing additional emergent activities, such as administering Atropine, Dopamine, and Epinephrine, and identifying and treating underlying causes.
• If Atropine is ineffective, consider transcutaneous pacing and/or Dopamine infusion or Epinephrine infusion.
• Identify and treat underlying causes, such as maintaining a patent airway, assisting breathing as necessary, providing oxygen (if hypoxemic), and monitoring blood pressure and oximetry.
• Hypovolemia, hypoxia, hydrogen ion (acidosis), hypokalemia/hyperkalemia, hypothermia, tension pneumothorax, tamponade, cardiac toxins, thrombosis, pulmonary thrombosis, and coronary thrombosis should be considered for emergent cardiac intervention if STEMI is present, unstable cardiogenic shock is present, or mechanical circulatory support is required.
• TTM should be started as soon as possible, beginning at 32-36°C for 24 hours by using a cooling device with feedback loop.
• For amiodarone IV/IO dose, use first dose of 300 mg bolus and second dose of 150 mg.
• Vagal maneuvers and Adenosine are options to treat tachyarrhythmia.
• Persistent tachyarrhythmia causing symptoms include hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, acute heart failure, and wide QRS complex.
• Follow the maintenance infusion of Amiodarone with a dose of 1 mg/min for the first 6 hours.
• If the rhythm is regular narrow complex, consider adenosine for synchronized cardioversion.
• If refractory to vagal maneuvers and Adenosine, consider an expert consultation.