ACLS Guidelines Overview

What is ACLS?

• Advanced airway management
• IV/IO vascular access
• Vasopressor and antiarrhythmic medications
• Advanced physiologic monitoring (ET CO₂, arterial BP, oximetry, ultrasound)
• Rhythm diagnosis and targeted treatment

The Core Framework: Shockable vs. Non-Shockable Rhythms

Shockable Rhythm Algorithm (VF / Pulseless VT)

1. Chest compressions 100–120/min → Immediate defibrillation → Resume CPR 2 min
2. If no ROSC → 2 min CPR + repeat shock
3. If no ROSC → IV/IO access + advanced airway + Epinephrine 1 mg q3–5 min + repeat shock
4. If no ROSC → IV Amiodarone 300 mg (may repeat 150 mg) + continue CPR + repeat shock
5. Specific therapies based on rhythm subtype (see below)

• Polymorphic VT/VF: lidocaine, PCI (if ACS); long QT → Mg, transvenous pacing, isoproterenol; Brugada/idiopathic VF → isoproterenol, quinidine
• Monomorphic VT: lidocaine, procainamide
• Sinusoidal VT (hyperkalemia): Ca²⁺, NaHCO₃; if ACS or drug toxicity — specific reversal
• Asystole / PEA: Address reversible causes (H's & T's)

Airway Management

• Both bag-mask ventilation (BMV) and advanced airway (ETI or supraglottic airway/SGA) are acceptable per 2019 AHA/ACC guidelines
• BMV: ~600 mL per breath over 1 second with tight face seal
• Advanced airway: 1 breath every 6 compressions (10/min)
• SGA is preferred over ETI when operator experience is limited or ETI success is expected to be low
• A large RCT (n=2040) showed no survival difference between BMV and ETI

Medications

Epinephrine note: A trial of 8,014 patients showed slightly higher 30-day survival with epinephrine vs. placebo (3.2% vs 2.4%, P=0.02), but no difference in favorable neurologic outcome (2.2% vs 1.9%). — Fuster and Hurst's The Heart, 15th Ed.

Monitoring During ACLS

Reversible Causes — The "H's and T's"

Special Situations

Patients with Pacemakers / AICDs

• CPR can be performed in standard fashion
• If AICD shocks are impeding CPR, disable it with a magnet over the device corner
• Place defibrillation pads ≥10 cm from the pulse generator
• Use anteroposterior pad placement to minimize energy shunting
• After ROSC, interrogate the device promptly — Roberts and Hedges' Clinical Procedures in Emergency Medicine

LVAD Patients

• Ensure LVAD is connected, battery charged, and audible hum is present
• Peripheral pulses may be absent at baseline — complicate arrest assessment
• Follow standard ACLS algorithms if arrest confirmed

Pediatric Considerations

• Cardiac arrest in children is usually secondary to respiratory arrest (not primary cardiac)
• VF/pVT is less common in children (3–17% vs. majority in adults)
• Defibrillation dose: 2 J/kg initial, increasing to 4 J/kg if needed
• Common terminal rhythms in children: PEA, bradycardia, asystole

When to Stop ACLS