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Hard, fast, unrelenting chest compressions are the core of ACLS!!!

Step 1: Check the Patient’s Pulse

  • If the patient does not have a pulse, start CPR
    • Hard, fast, unrelenting compressions
      • Intubated patients
        • Continuous Compressions
      • Non-intubated adults
        • 30 compressions then 2 breaths… Repeat
      • Non-intubated pediatrics
        • 15 compressions then 2 breaths… Repeat

Step 2: Determine if the Rhythm is Shockable or Non-shockable

  • Shockable rhythms
    • Ventricular Fibrillation (VF)
    • Ventricular Tachycardia (VT)
  • Non-shockable rhythms
    • Pulseless electrical activity (PEA)
    • Asystole

Step 3: Start a Timer For 2 Minutes

  • Do a rhythm/pulse check every 2 minutes

Step 4: Is the Patient in a Shockable Rhythm?

  • Repeat/coordinate shocks with every 2-minute pulse check
  • Give 1mg IV/IO epinephrine every 3-5 minutes
  • Give amiodarone
    • 300mg with first dose
    • 150mg with a repeat dose

Step 5: Is the Patient in a Non-Shockable Rhythm?

  • Give epinephrine every 4 minutes (every other cycle)

Quick Facts

  • Shockable rhythms (VT/VF) have best prognosis
    • Frequently related to myocardial infarction
  • Asystole has the worst prognosis
  • PEA has mixed prognosis (depends on diagnosis)
    • Two types (wide and narrow)
      • “Wide” PEA frequently caused by metabolic abnormalities
        • Consider bicarb and calcium chloride
      • “Narrow” PEA frequently caused by shock state
        • Perform bedside ultrasound in attempt to determine cause
    • “The H’s and T’s”
      • Hypoxemia
      • Hypovolemia
      • Hydrogen Ions
      • Hyper/hypokalemia
      • Tension pneumothorax
      • Tamponade
      • Toxins
      • Thrombosis (MI/PE)

Additional Reading