Adult Resuscitation

Aka: Adult Resuscitation, ACLS, Advanced Cardiac Life Support

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II. Precautions: General

  1. See Resuscitation Precautions
  2. See Emergency Department Preparation for Resuscition
  3. See Special Circumstances When Ceasing Resuscitation Efforts

III. Precautions: Updates based on ACLS Guidelines (2010, 2025)

  1. Mnemonic is 'C-A-B' to emphasize compressions
    1. Cardiac Compressions are a first line intervention
    2. Chest Compressions are started within 10 seconds of recognition of arrest
      1. Health care providers start with a pulse check prior to compressions
      2. First-responders start compressions without a pulse check to minimize delays
    3. Compressions are hard (at least 2 inches or 5 cm deep in adults)
    4. Compressions are fast (30 compressions within 18 seconds)
      1. Avoid rates above 140 beats per minute (associated with worse outcomes)
      2. Idris (2012) Circulation 125(24): 3004-12 [PubMed]
    5. Experimental: Optimal Compression Site (based on TEE data)
      1. Optimal compression site may be 4 cm to the left of Sternum
      2. Sternal compressions (standard CPR position) may compress the LVOT and impede outflow
      3. Do NOT modify standard sternal compression site as of 2026 unless directed by TEE and local expert opinion
      4. Swaminathan and Derr (2026) CPR Hand Placement, EM:Rap, 3/9/2026
    6. Hands-only CPR (without breaths) is recommended for untrained rescuers
  2. Foreign Body Aspiration
    1. In responsive patients, start with 5 back blocks and 5 abdominal thrusts (same as children)
  3. Cardiac Compressions are continued, interrupted only for <10 seconds for rhythm checks and Defibrillation
    1. Bedside focused Echocardiogram performed during rhythm checks
    2. Intubate without interrupting compressions
  4. Automatic compression devices (e.g. Lucas) are recommended where available
    1. Improved short-term outcomes (but not long-term outcomes to date)
  5. Targeted Temperature Management (ACLS 2025)
    1. See Induced Therapeutic Hypothermia
    2. Indications
      1. Adults with ROSC who cannot follow commands
    3. Improved neurologic outcomes in patients with ROSC
    4. Targeted Temperature Management (prevent hyperthermia or fever) is key
      1. Maintain Temperature 32 C (89.6 F) to 37.5 C (99.5 F)
      2. Aggressive Hypothermia to <33 C does not have better outcomes than 36 C
      3. Protective effects appear more related to the prevention of fever or hyperthermia
      4. Neilsen (2013) N Engl J Med 369: 2197-206 +PMID: 24237006 [PubMed]
  6. Start charging the Defibrillator before CPR is paused (decreases hands-off time)
    1. Defibrillator fully charged when CPR paused
    2. Immediate shock can be delivered at rhythm check and CPR resumed
    3. Edelson (2010) Resuscitation 81(11):1521-6 +PMID:20807672 [PubMed]
  7. Avoid cardiac compression interruptions (minimize most procedures until ROSC)
    1. Obtain early IV Access (or IO Access if failed 2 attempts)
      1. Defer early central venous access or Arterial Lines until ROSC
    2. Avoid early intubation (see above)
      1. Consider Supraglottic Airway (e.g. LMA) to assist oxygenation and ventilation
  8. Medications
    1. Avoid empiric Calcium outside of suspected Hyperkalemia
    2. Avoid empiric bicarbonate
    3. Avoid empiric Magnesium outside of specific indications (e.g. Torsades de Pointes)

IV. Management: Assess Responsiveness

  1. Responsive
    1. See Rapid ABC Assessment
  2. Unresponsive
    1. See Altered Level of Consciousness
    2. Call for Help
      1. Call for Defibrillator if available
      2. Activate EMS after initial ABC assessment

V. Management: Emergency Airway

  1. See Primary Survey Airway Evaluation
  2. Position
    1. Turn on back as unit
    2. Support head and neck while positioning
    3. Place on hard firm surface
  3. Open airway
    1. Jaw Thrust (if suspected neck injury)
    2. Head Tilt-Chin Lift Maneuver

VI. Management: Emergency Breathing

  1. See Primary Survey Breathing Evaluation
  2. Breathing is assessed by medical providers concurrently with responsiveness
    1. Look Listen and feel for breathing has been removed from the ACLS and PALS sequence
  3. Rescue breaths are now started after one cycle of compressions (in Cardiac Arrest)
    1. New sequence: Compressions, open airway, give breaths
  4. Attempt 2 ventilations (each lasting 1 second) if not breathing
    1. Observe chest rise
    2. Allow deflation between breaths
    3. Reposition if first breath does not go in
  5. Airway Obstruction (if ventilations unsuccessful)
    1. No blind finger sweeps at any age
    2. Unconscious
      1. Deliver full CPR regardless of airway obstruction
    3. Conscious
      1. Perform Heimlich Maneuver
        1. Infants: 5 chest thrusts and 5 back blows
        2. Children: 5 abdominal thrusts
        3. Adults: 6-10 abdominal thrusts
      2. Attempt ventilation
      3. Repeat cycle until obstruction cleared

VII. Management: Emergency Circulation

  1. See Primary Survey Circulation Evaluation
  2. Assess for Pulse (health care providers)
    1. Brachial Pulse in infants
    2. Carotid Pulse in children and adults
  3. Pulse Present: Perform Rescue Breathing (reassess every 2 minutes)
    1. Endotracheal Tube: 1 breath per 6-8 seconds for all ages (8 to 10 breaths per minute)
    2. Adult: 10 breaths per minute (every 6 seconds) in BLS
      1. Replaces Adult: 12 breaths/min (every 5 sec)
    3. Infant and Child breaths: 20-30 breaths/min (every 2-3 seconds) in BLS
      1. Replaces Child: 15 breaths per minute (every 4 seconds)
      2. Replaces Infant: 20 breaths per minute (every 3 seconds)
  4. Pulse Absent: Chest Compressions
    1. General
      1. Pulse check should be <10 seconds
        1. EtCO2 is a reliable marker for ROSC (if pulses are difficult to palpate)
        2. Bedside Ultrasound may prolong pulse checks (restart compressions on timer)
        3. Huis (2017) Resuscitation 119:95-98 PMID:28754527 [PubMed]
      2. Perform 5 cycles in 2 minutes
      3. Reassess pulse and rhythm every 2 minutes
      4. Focus on pressing hard and fast with minimal interruptions
      5. Connect Automatic External Defibrillator as soon as available
      6. Time interval for lone rescuer calling for help
        1. Sudden Collapse: Call immediately
          1. Minimizes time to AED application
        2. Asphyxial arrest: Perform CPR for 2 minutes
      7. Two rescuers switch places every 2 minutes
        1. Prevents rescuer Fatigue with Chest Compressions
        2. Repeat pulse and rhythm checks with the change
    2. Infants (Under 1 year old)
      1. Place 2 fingers at just below mid-nipple line
        1. Alternatively, hands encircle chest and both thumbs compress chest
      2. Compress over 100 times per minute
        1. Depth: One third of chest depth (1.5 inches or 4 cm)
        2. Compression to ventilation ratio
          1. Infant <1 month old: 3:1
          2. One rescuer: 30:2
          3. Two health care providers: 15:2
    3. Children (1-8 years old)
      1. One hand placed over Sternum at center of chest (superior to xiphoid)
      2. Compress over 100 times per minute
        1. Depth: One third of chest depth (2 inches or 5 cm)
        2. Compression to ventilation ratio
          1. One rescuer: 30:2
          2. Two health care providers: 15:2
    4. Adults (over 8 years old)
      1. Two hands placed over Sternum at center of chest (superior to xiphoid)
      2. Compress 100 times per minute
        1. Depth: 2 inches or 5 cm
        2. Compression to ventilation ratio: 30:2 (one or two rescuers)

VIII. Management: Rhythm - Pulse Absent in adults and children (ACLS and PALS)

  1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  2. Shockable Rhythm: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
    1. Defibrillate every 2 minutes
      1. Adult: Biphasic dose varies by device (120-200 J); Monophasic dose 360 J
      2. Children: Start at 2-4 J/kg, then 4 J/kg
      3. Start charging the Defibrillator before CPR is paused (decreases hands-off time)
        1. See above for reference
    2. CPR
      1. Performed continuously between shocks (minimal interruptions)
    3. Alpha-adrenergic agent (choose one)
      1. Epinephrine
        1. Adult: 1 mg every 3-5 minutes
        2. Child: 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
      2. Vasopressin (not commonly used in community EDs and removed from 2015 ACLS guidelines)
        1. Adult: 40 units for 1 dose
    4. Antiarrhythmic
      1. Amiodarone (preferred)
        1. Adult: 300 mg IV (may subsequently repeat once at dose 150 mg)
        2. Child: 5 mg/kg bolus (and may be repeated up to twice for refractory VF/VT)
      2. Lidocaine (alternative for adults, not recommended in children)
        1. Adult: 1-1.5 mg/kg IV (may subsequently repeat dose at 0.5 to 0.75 mg/kg)
        2. Prior to 2002 Alive Trial, Lidocaine had been the primary agent in VT/VF
          1. However, In 2023-2025 several studies have shown improved survival with Lidocaine
        3. Lidocaine is a cleaner drug, acting only at Sodium channels, with onset in seconds (duration <20 min)
          1. Contrast with Amiodarone which blocks multiple channels (Na+, K+, Ca++, beta) and delayed peak
        4. Lidocaine is preferred in certain scenarios
          1. Brugada Syndrome
          2. Torsades de Pointes (after Magnesium)
          3. Ischemia related Ventricular Tachycardia
        5. References
          1. Swaminathan and Hedayati (2026) Anti-Dysrhythmics in VT/VF Arrest, EM:Rap 4/6/2026
    5. Magnesium (for Torsades de Pointes)
      1. Adult: 1-2 g IV
      2. Child: 25 to 50 mg/kg IV or IO
  3. Non-shockable Rhythm: Asystole or Pulseless Electrical Activity (PEA)
    1. Key management is to identify and treat Reversible Causes of Cardiopulmonary Arrest (5H5T)
    2. Epinephrine
      1. Adult: 1 mg every 3-5 minutes
      2. Child: 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
    3. Vasopressin (not commonly used in community EDs and out of 2015 AHA guidelines)
      1. Adult: 40 units for 1 dose
    4. Atropine is no longer recommended as of 2010 guidelines
      1. Was previously given at 1 mg IV for Asystole or Slow PEA
  4. Other experimental measures
    1. Vasopressin 20 units
      1. No longer part of AHA pulseless algorithm guidelines as of 2015 (prior alternative to epi)
      2. Vasopressin is given in addition to Epinephrine per protocol
        1. Vasopressin may be better at maintaining brain perfusion
        2. Epinephrine appears better at achieving ROSC
      3. Consider Vasopressin when low End-Tidal CO2 (e.g. 20) despite high quality CPR
      4. Early studies suggest improved survival
      5. Orman and Weingart in Herbert (2015) EM:Rap 15(1): 14-6
      6. Mentzelopoulus (2013) JAMA 310(3): 270-9 [PubMed]
    2. Esmolol
      1. May be considered for refractory Ventricular Fibrillation in adults (based on small study)
      2. Dose: 500 mcg/kg (folllowed by infusion at 0-100 mcg/kg/min)
      3. Driver (2014) Resuscitation 85(10): 1337-41 +PMID:25033747 [PubMed]
    3. Double sequential external Defibrillation
      1. Two Defibrillators with pads right-left, front-back deliver maximal shock simultaneously
      2. May be considered in refractory Ventricular Fibrillation in adults (esp. obese)
      3. Cheskes (2023) Intensive Care Med 49(4):455-7 +PMID: 36754880 [PubMed]
  5. Other measures to avoid unless specifically indicated
    1. Empiric Calcium Administration (without specific indication)
      1. Routine Calcium administration is associated with worse outcomes in out of hospital Cardiac Arrest
      2. Messias Hirano Padrao (2022) Resusc Plus 12:100315 +PMID: 36238582 [PubMed]

IX. Management: Rhythm - Pulse Present - Unstable in adults and children (ACLS and PALS)

  1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  2. Indications for Unstable Status
    1. Chest Pain
    2. Hypotension or other signs of shock
    3. Altered Level of Consciousness
  3. Bradycardia (symptomatic with hemodynamic instability)
    1. See Unstable Bradycardia
    2. Perform CPR in children for Heart Rate <60/min with signs of hypoperfusion
    3. Atrioventricular Block (AV Block): Mobitz 2 or third degree
      1. Transcutaneous Pacing
      2. Prepare for Transvenous Pacing
    4. No AV Block (or first degree or Wenckebach)
      1. Adults
        1. Atropine 0.5 mg IV (may repeat up to a cummulative total of 3 mg)
        2. Transcutaneous Pacing
        3. Chronotropes (alternative to Transcutaneous Pacing)
          1. Epinephrine 2-10 mcg/min
          2. Dopamine 2-10 mcg/kg/min
      2. Children
        1. Epinephrine 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
        2. Atropine 0.02 mg/kg and may repeated once (min to max dose: 0.1 mg to 0.5 mg)
          1. Indicated if increased vagal tone or primary Atrioventricular Block
        3. Transcutaneous Pacing
  4. Tachycardia: Synchronized Cardioversion
    1. See Unstable Tachycardia
    2. Conscious Sedation if no delays
    3. Adults
      1. Atrial Arrhythmia
        1. Start at 200 joules biphasic (per ACLS 2025)
        2. Prior guidelies: 120 J biphasic for PSVT, Atrial Flutter; 120 J for Atrial Fibrillation
      2. Ventricular Arrhythmia
        1. Monomorphic Ventricular Tachycardia
          1. Synchronized Cardioversion or Defibrillation 200 J biphasic, 360 J monophasic
        2. Polymorphic Ventricular Tachycardia
          1. Immediate Defibrillation at 200 J biphasic, 360 J monophasic (ACLS 2025)
    4. Children
      1. Initial: 0.5 to 1 J/kg
      2. Refractory: 2 J/kg

X. Management: Rhythm - Pulse Present - Stable - Bradycardia in adults and children (ACLS and PALS)

  1. Indicated if unstable criteria above not met
  2. Bradycardia
    1. Evaluate for Sinus Bradycardia causes
    2. Observe for change in status

XI. Management: Rhythm - Pulse Present - Stable - Tachycardia in Adults (ACLS)

  1. Indicated if unstable criteria above not met
  2. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  3. Wide Complex Tachycardia (QRS wider than 0.12 msec)
    1. Regular Wide Complex Tachycardia
      1. Start with Adenosine 6 mg IV (may repeat with 12 mg IV)
        1. Benign and slows the rhythm for interpretation
        2. Helps to differentiate SVT with aberrancy from VT
      2. Supraventricular Tachycardia with Aberrancy
        1. Treat as Regular Narrow Complex Tachycardia (see below)
      3. Ventricular Tachycardia
        1. Synchronized Cardioversion
        2. Amiodarone 150 mg IV over 10 min (followed by infusion)
          1. Procainamide is more effective than Amiodarone
          2. Procainamide may be preferred if no CHF or Prolonged QT Interval
        3. Alternative Antiarrhythmics
          1. Procainamide (if no CHF and no Prolonged QT Interval)
          2. Sotalol 100 mg (1.g mg/kg) IV over 5 min (if no Prolonged QT Interval)
    2. Irregular Wide Complex Tachycardia
      1. Atrial Fibrillation with WPW
        1. Amiodarone 150 mg IV
        2. Consult with cardiology
        3. Avoid Beta Blockers, Calcium Channel Blockers, Digoxin, Adenosine
      2. Atrial Fibrillation with aberrancy
        1. Treat as Irregular Narrow Complex Tachycardia (see below)
      3. Torsades de Pointes
        1. Magnesium 1-2 grams IV
        2. Synchronized Cardioversion (or Defibrillation if unable to sync)
        3. Over-drive Transcutaneous Pacing
  4. Narrow Complex Tachycardia
    1. Regular Narrow Complex Tachycardia
      1. Vagal Maneuvers
      2. Adenosine 6 mg and may repeat at 12 mg dose
        1. Conversion with Adenosine suggests Paroxysmal Supraventricular Tachycardia (PSVT)
        2. Recurrence can be treated with Adenosine, Diltiazem or Lopressor
      3. Rate control
        1. Rate control with Diltiazem or Lopressor (see below)
        2. Refractory to Adenosine causes
          1. Atrial Flutter
          2. Ectopic Atrial Tachycardia
          3. Junctional Tachycardia
    2. Irregular Narrow Complex Tachycardia
      1. Occurs with Atrial Fibrillation, Atrial Flutter or Multifocal Atrial Tachycardia (MAT)
      2. Avoid Adenosine (risk of Ventricular Fibrillation)
      3. Rate control
        1. Diltiazem
          1. Bolus 1: 20 mg (0.25 mg/kg) IV bolus over 2 min
          2. Bolus 2: 25 mg (0.35 mg/kg) IV bolus over 2 min
            1. Administer if indicated, and at least 15 min after first
          3. Drip: 10 mg/hour (typical range: 5-15 mg/hour)
        2. Metoprolol (Lopressor)
          1. Avoid in acute CHF or COPD exacerbation
          2. Bolus: 2.5 to 5 mg IV every 2-5 min (maximum 15 mg in 15 min)

XII. Management: Additional measures

  1. See Reversible Causes of Cardiopulmonary Arrest
  2. See Post-Cardiac Arrest Care
  3. Post-arrest pronouncement in the emergency department
    1. Consider a moment of silence for deceased patient at end of Resuscitation attempt
    2. Strayer in Herbert (2018) EM:Rap 18(2): 3

XIII. Resources

  1. Cardiopulmonary Resuscitation Guidelines
    1. http://www.circulationaha.org

XIV. References

  1. Trauma
    1. (2008) ATLS Manual, American College of Surgeons
    2. Majoewsky (2012) EMR:RAPC3 2(1): 1-2
  2. Cardiopulmonary Resuscitation Guidelines
    1. Mace (2013) Crit Dec Emerg Med 27(1): 11-20
    2. Mace (2013) Crit Dec Emerg Med 27(2): 2-10
    3. (2010) Guidelines for CPR and ECC [PubMed]
    4. (2005) Circulation 112(Suppl 112):IV [PubMed]
    5. (2000) Circulation, 102(Suppl I):86-9 [PubMed]

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