Adult Cardiac Arrest Algorithm

The Cardiac Arrest Algorithm is the most critical algorithm of ACLS. When you have a patient without a pulse, you must recognize either ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) as shockable rhythms. In contrast, you do not shock PEA or asystole, and must follow another pathway of the Cardiac Arrest Algorithm.

When to Use This Algorithm

This algorithm is used when an adult patient experiences cardiac arrest. Signs include unresponsiveness, absence of normal breathing, and no detectable pulse. Immediate action is crucial to improve the chances of survival.

Immediate Actions

1. Start CPR
   • Begin cardiopulmonary resuscitation (CPR) immediately.
   • Provide oxygen and attach a monitor/defibrillator.
   • Ensure chest compressions are performed at a rate of 100-120 per minute with a depth of at least 2 inches, allowing full chest recoil.
2. Identify Rhythm: VF/pVT (Ventricular Fibrillation/Pulseless Ventricular Tachycardia)
   • Check if the rhythm is shockable.
   • Quickly assess the rhythm on the monitor, ensuring minimal interruption in chest compressions.
3. Administer Shock
   • Deliver an electric shock using a defibrillator if a shockable rhythm is present.
   • Clear the area around the patient to avoid accidental shock to rescuers.
4. Perform CPR (2 Minutes)
   • Continue CPR for 2 minutes.
   • Gain IV/IO access for medication administration.
   • Rotate compressors every 2 minutes to prevent fatigue and maintain high-quality compressions.

Rhythm Check

• Is Rhythm Shockable?
  • If yes, proceed to shock and CPR cycles.
  • If no, move to the PEA/Asystole pathway.

Shock and CPR Cycles

5. Administer Shock
   • Deliver another shock if the rhythm is shockable.
6. Perform CPR (2 Minutes)
   • Continue CPR for 2 minutes.
   • Administer epinephrine 1 mg every 3-5 minutes.
   • Decide on advanced airway management and capnography.
   • Consider using a mechanical CPR device if available to ensure consistent compressions during transport.
7. Administer Shock
   • Deliver a third shock if the rhythm is still shockable.
8. Perform CPR (2 Minutes)
   • Continue CPR for 2 minutes.
   • Administer antiarrhythmic drugs like amiodarone or lidocaine.
   • Look for and treat reversible causes.
   • During this phase, ensure the team is aware of potential reversible causes (e.g., H’s and T’s: hypoxia, hypovolemia, hyperkalemia, hypothermia, toxins, tension pneumothorax, tamponade, thrombosis).

Non-Shockable Rhythm: PEA/Asystole

9. PEA/Asystole
   • Identify if the rhythm is Pulseless Electrical Activity (PEA) or Asystole.
   • Ensure high-quality CPR and minimal interruptions while searching for reversible causes.
10. Administer Epinephrine ASAP
    • Give epinephrine as soon as possible.
    • Administer 1 mg of epinephrine every 3-5 minutes.
    • Gain IV/IO access, decide on advanced airway management, and monitor with capnography.
    • Use capnography to monitor CPR effectiveness; an ETCO2 reading <10 mmHg indicates inadequate compressions.
11. Perform CPR (2 Minutes)
    • Continue CPR for 2 minutes.
    • Look for and treat reversible causes.
    • Frequent rhythm checks should be brief (less than 10 seconds) to avoid prolonged interruptions in compressions.

Rhythm Check

• Is Rhythm Shockable?
  • If yes, return to the shock and CPR cycles.
  • If no, continue with the PEA/Asystole pathway and epinephrine administration.

Return of Spontaneous Circulation (ROSC)

12. Evaluate ROSC
    • If signs of Return of Spontaneous Circulation (ROSC) are present, transition to post-cardiac arrest care.
    • If no ROSC, repeat cycles as directed, focusing on rhythm checks and appropriate interventions.
    • During ROSC, ensure comprehensive post-cardiac arrest care, including optimizing ventilation and oxygenation, treating hypotension, and considering targeted temperature management.

Key TakeawaysEffective management of adult cardiac arrest involves immediate CPR, timely defibrillation for shockable rhythms, and continuous reassessment of the patient's condition. Administering medications like epinephrine and antiarrhythmics, along with addressing reversible causes, are crucial steps. Always be prepared to transition to post-cardiac arrest care upon achieving ROSC to ensure the best possible outcomes for the patient.