Adult Cardiac Arrest Management

Core Principles

The American Heart Association recommends following the 2020 ACLS guidelines for adult cardiac arrest, which provide specific drug dosages, including epinephrine 1 mg IV/IO every 3-5 minutes for all rhythms, and for refractory VF/pVT, amiodarone 300 mg first dose followed by 150 mg second dose, or alternatively lidocaine 1-1.5 mg/kg first dose followed by 0.5-0.75 mg/kg second dose 1, 2, 3
High-quality CPR forms the foundation of all ACLS interventions, with key metrics including compression depth of at least 2 inches, compression rate of 100-120 compressions per minute, complete chest recoil between compressions, minimizing interruptions in chest compressions, avoiding excessive ventilation, and rotating compressors every 2 minutes or sooner if fatigued 1, 2, 4

For shockable rhythms, deliver shocks immediately followed by 2 minutes of CPR, with biphasic defibrillators using the manufacturer's recommended energy dose, and subsequent shocks being equivalent or higher doses 1, 2
Administer antiarrhythmics after defibrillation attempts for persistent or recurrent VF/pulseless VT, with amiodarone 300 mg IV/IO bolus as the first dose, followed by 150 mg IV/IO as the second dose, or lidocaine 1-1.5 mg/kg IV/IO as the first dose, followed by 0.5-0.75 mg/kg IV/IO as the second dose 1, 2, 3, 4

The American Heart Association recommends administering epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms, with a standard dose that may be reasonable despite uncertainty about long-term neurological outcomes, as it improves short-term outcomes including ROSC and hospital admission 1, 2, 3, 5

Once an advanced airway is placed, use endotracheal intubation or supraglottic advanced airway, confirm placement with waveform capnography or capnometry, deliver 1 breath every 6 seconds with continuous chest compressions, and do not pause for ventilation once the advanced airway is secured 1, 2, 3

Stop CPR and assess when any of the following occur: palpable pulse and blood pressure return, abrupt sustained increase in PETCO₂, or spontaneous arterial pressure waves with intra-arterial monitoring, and search for and treat potentially reversible causes throughout resuscitation, including hypovolemia, hypoxia, hydrogen ion acidosis, hypo-/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, pulmonary thrombosis, and coronary thrombosis 1, 2, 3

The circular ACLS algorithm emphasizes continuous cycles, with steps including checking rhythm every 2 minutes, shocking for VF/pVT followed by immediate CPR for 2 minutes, establishing IV/IO access as soon as feasible, giving epinephrine every 3-5 minutes throughout, and considering antiarrhythmics for refractory VF/pVT after initial shocks 1, 2, 4

The American Heart Association recommends administering the first dose of 300 mg IV/IO bolus of amiodarone after the third unsuccessful defibrillation attempt in patients with refractory VF/pVT 6, 7, 8
The American Heart Association recommends administering the second dose of 150 mg IV/IO bolus of amiodarone for persistent or recurrent VF/pVT after additional shock(s) in patients with refractory VF/pVT 6, 7

The American Heart Association acknowledges that the optimal timing of antiarrhythmic administration in relation to shock delivery is unknown 7, 8, 9

The American Heart Association recommends administering a total dose of 300-450 mg of amiodarone, with recent observational data suggesting that 300 mg total may be sufficient compared to 450 mg 6, 7

The American Heart Association recommends not administering both doses of amiodarone back-to-back, reserving the second dose for ongoing refractory rhythm 6
The American Heart Association recommends continuing high-quality compressions with minimal interruptions, without delaying CPR to administer medications 6