Cardiopulmonary Resuscitation

Aka: Cardiopulmonary Resuscitation, ABC Management, Adult Resuscitation, Pediatric Resuscitation, Resuscitation, CPR, Cardiac Arrest, Peri-Arrest, ACLS, Advanced Cardiac Life Support, PALS, Pediatric Advanced Life Support

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II. Epidemiology

  1. Pediatric Cardiac Arrest Incidence: 3.3 to 8 cases per 100,000 in U.S.
    1. Out of hospital arrest ROSC: 23% (10% survival rate)
    2. Best ROSC and survival rates are for teen Cardiac Arrests (infants have the lowest rates)
  2. Neurologically Intact Survival after out-of-hospital Cardiac Arrest
    1. Infant: 1 to 2%
    2. Child: 4%
    3. Teen: 11 to 16%
    4. Adult: 2 to 10%
  3. U.S. black and hispanic patients are significantly less likely to receive bystander CPR (home or public setting)
    1. Garcia (2022) N Engl J Med 387(17):1569-78 +PMID: 36300973 [PubMed]

III. Precautions

  1. Peri-Arrest (Unstable Arrhythmia)
    1. Per-arrest refers to unstable Arrhythmia that will degenerate into Cardiac Arrest if no immediate intervention
    2. Brief window of opportunity between Peri-Arrest and Cardiac Arrest (treat it as a code situation)
    3. Situations in which prompt management may prevent Cardiac Arrest
      1. Arrhythmia associated with Chest Pain, Heart Failure or shock
      2. Unstable Tachycardia (esp. Ventricular Tachycardia with a pulse)
      3. Unstable Bradycardia
    4. References
      1. Adaka in Herbert (2017) EM:Rap 17(1): 3-4
  2. Epinephrine in Cardiac Arrest
    1. Epinephine appears to have its most beneficial effects in the first 15-20 minutes of onset
      1. Tanaka (2016) Am J Emerg Med 34(12): 2284-90 [PubMed]
    2. After the first 15-20 minutes, Epinephrine may worsen outcomes
      1. Heart at this point has moved from electrical phase (first 5 min) and circulatory phase (10-15 min)
      2. Heart enters metabolic phase with myocardial necrosis, which may be worsened by Epinephrine
      3. Orman and Mattu in Herbert (2017) EM:Rap 17(8): 5
  3. Early intubation during Resuscitation decreases survival
    1. Intubation within first 15 minutes was associated with decreased survival
    2. Focus on effective interventions (high quality CPR, Defibrillation, Reversible Causes of Cardiopulmonary Arrest)
    3. Anderson (2017) JAMA 317(5): 494-506 +PMID: 28118660 [PubMed]
  4. Prehospital extraglottic airways (LMA, I-Gel) offer at least equal if not better survival benefit in out-of-hospital Cardiac Arrest
    1. Bag-Valve-Mask in pediatric patients is a reasonable alternative to Supraglottic Devices and intubation (PALS 2019)
    2. Benger (2018) JAMA 320(8):779-91 +PMID:30167701 [PubMed]
    3. Wang (2018) JAMA 320(8):769-78 +PMID:30167699 [PubMed]
  5. Masseter Spasm preventing Endotracheal Intubation in Cardiac Arrest
    1. Rare, but well reported phenomenon, that may be confused with rigor mortis (despite short-arrest time)
    2. If no response to high dose paralytics, move quickly to surgical airway (Cricothyrotomy)
    3. Lee (2012) Am J Emerg Med 30(6):1014.e1-2 +PMID: 21676574 [PubMed]
    4. Swaminathan and Weingart (2024) Critical Care Hodgepodge, EM:Rap 7/7/2024
  6. Patients who awaken during Cardiac Arrest
    1. High quality CPR (esp with compression devices) may result in a conscious patient before ROSC
    2. Consider Ketamine 1 mg/kg IV which is least likely to affect hemodynamics and successful ROSC
    3. Weingart and Swaminathan in Herbert (2022) EM:Rap 22(2): 2-4
  7. Echocardiogram during Resuscitation
    1. Precautions
      1. Ultrasound during pulse checks doubles the time without Chest Compressions
      2. Have staff count down during pulse check from 10 to 0, and remove Ultrasound probe at 2
      3. Consider recording a 6 second Ultrasound video that can be reviewed after Chest Compressions resume
      4. Avoid using with each pulse check (only use with specific goal, e.g. confirm Asystole)
      5. Orman and Reed in Herbert (2018) EM:Rap 18(3): 3-4
      6. Huis (2017) Resuscitation 119:95-8 +PMID:28754527 [PubMed]
    2. Identifies Reversible Causes of Cardiopulmonary Arrest
      1. Cardiac Tamponade
      2. Hypovolemia
      3. Tension Pneumothorax
      4. Myocardial Infarction
      5. Pulmonary Embolism
      6. Hemorrhagic Shock (e.g. Ruptured Abdominal Aortic Aneurysm, Trauma)
    3. Cardiac activity definition
      1. Intrinsic myocardial movement
      2. Isolated cardiac valve movement occurs with minimal Fluid Shifts (3 mmHg) and is NOT cardiac activity
      3. Absence of cardiac activity on ulrasound is not recommended as a prognostic indicator (AHA 2020)
        1. ROSC is ultimately achieved in 2.4% of patients without wall motion on Ultrasound
          1. Blyth (2012) Acad Emerg Med 19(10):1119-26 +PMID: 23039118 [PubMed]
        2. Cardiac standstill has variable inter-rater reliability
          1. Hu (2018) Ann Emerg Med 71(2):193-8 +PMID: 28870394 [PubMed]
    4. Monitors Compression quality
      1. Consider using Ultrasound over the femoral artery to follow circulation, compression quality
    5. References
      1. Swaminathan, Andrus and Mallon in Herbert (2018) EM:Rap 18(1): 8-9
  8. ECMO-Assisted CPR (PALS-2019)
    1. Consider for in-hospital pediatric arrest in known Congenital Heart Disease or Myocarditis
    2. Survival 48-73% for ECMO-assisted compared with 29-44% for standard CPR and in hospital arrest
    3. However, good neurologic outcome at 12 months in 30% of Cardiac Arrest revived with ECMO-Assisted CPR
    4. Claudius and Behar in Herbert (2020) EM:Rap 20(10): 9

IV. Protocol

  1. ATLS is integrated with ACLS and PALS for the purposes of this reference
    1. Typically ACLS, ATLS, PALS are taught in isolation (outside CALS Course)
  2. PALS and APLS (2019 guidelines)
    1. Rapid global assessment tool
      1. See Pediatric Assessment Triangle
    2. Most pediatric Cardiac Arrests result from respiratory decompensation
    3. Obtain IO Access while attempting IV Access
    4. Bag-valve-mask is a resonable alternative to Advanced Airway (LMA, Endotracheal Intubation) out of hospital
      1. ET Tube has no survival benefit over LMA, BVM when ventilating and oxygenating well
    5. Lucas Chest Compression System
      1. Lucas requires distance between compressor and the anterior chest pad must be <=15 mm
    6. ECMO may be considered in pediatric Cardiac Arrest patients with a cardiac diagnosis (e.g. Congenital Heart Disease)
      1. Efficacy relies on witnessed Cardiac Arrest, with early, high quality continuous CPR
    7. Targeted Temperature Management (TTM) of 36 C to 37.5 C appears equivalent to lower Temperature targets
      1. If TTM is used, may follow either target, and overall prevent fever >37.5 C (99.5 F)
    8. References
      1. Claudius and Donofrio-Odmann (2024) Pediatric Pearls: Pediatric Cardiac Arrest, EM:Rap, 11/25/2024
      2. Duff (2019) Circulation 140(24):e904-14 +PMID:31722551 [PubMed]
  3. ACLS guidelines 2010 focuses on Cardiac Compressions as the first line intervention
    1. Mnemonic is 'C-A-B' to emphasize compressions
      1. 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
      2. Compressions are hard (at least 2 inches or 5 cm deep in adults)
      3. 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]
      4. Hands-only CPR (without breaths) is recommended for untrained rescuers
    2. 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
    3. Automatic compression devices (e.g. Lucas) are recommended where available
      1. Improved short-term outcomes (but not long-term outcomes to date)
    4. Induced Therapeutic Hypothermia
      1. Improved neurologic outcomes in patients with ROSC
    5. 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]
    6. 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

V. Preparation: Emergency Department

  1. Pre-Briefing
    1. First 2-3 minutes prior to patient arrival is critical to successful Resuscitation and survival
    2. Gather Resuscitation team together prior to Ambulance arrival
      1. Review known information with expected course and interventions
      2. Discuss backup plans
      3. Leader scripts the first 3-5 minutes of Resuscitation with specific tasks for specific team members
    3. Roles are assigned prior to patient arrival (consider applying labels to front of gowns)
      1. Provider Running the Resuscitation or code stands at the foot of the bed
      2. Provider managing the airway and neurologic evaluation stands at the head of the bed
      3. Divide into teams for certain complex tasks (e.g. airway management)
  2. Preparation Mnemonic: AEIOU
    1. Advanced Airway equipment
      1. Place in Resuscitation room
      2. Provider responsible for airway is at head of bed
    2. End-Tidal CO2 detector
      1. Connect and prepare device
    3. Intraosseous Line
      1. Confirm IO kit is available
    4. Organization and Order
      1. Gather and role assignment (see above)
      2. Delegation of tasks allows for cognitive unloading (see above)
        1. See Decision Making Strategy
        2. Employ decision making aids (e.g. Broselow Tape)
      3. Sustain a Shared Mental Model
        1. Summarize and walk through decision making out loud
        2. Train together in simulations to develop strategy and patterns of communication
      4. Keep two way communication open
        1. Make team members comfortable with offering suggestions, feedback
        2. Team leader may ask "What am I missing?" to open conversation for suggestions
    5. Ultrasound
      1. Place in Resuscitation room and prepare (turn on, select probe and apply gel)
  3. Paramedic report and transfer of care should be initial focus on patient arrival
    1. Allow Paramedics to give history, findings, answer team questions, relay Resuscitation efforts
    2. Avoid chatter that interferes with the team hearing Paramedic report
  4. Additional team management techniques
    1. Establish clear leadership roles at the time of presentation
      1. Annnounce your role as team leader (if not already established in preparation as above)
      2. Be the sole voice in the room, periodically updating the team
      3. Elicit feedback throughout the code from team members
        1. Ask for additional ideas (e.g. "what am I missing?")
        2. Ask the medication nurse, is our Intravenous Access adequate?
        3. Ask the respiratory therapist, are the ventilations difficult?
    2. Use closed loop communication
      1. Use precise language directed at a specific person by name you intend to perform a task
      2. Practice clarification and acknowledgement of assigned tasks
      3. Divide clinical work evenly to avoid overwhelming individual team members
        1. Limit orders to no more than 2 to 3 per each team member at a time
    3. Offer feedback with graded assertiveness (Mnemonic: CUSS)
      1. Concern expressed regarding interventions with unclear reason or that are unsafe
      2. Uncomfortable
      3. Safety
      4. Stop
    4. Other measures
      1. Allow for patient access in a near 360 degree circle around the patient
      2. Ensure monitors are visible from all patient care positions
      3. Keep highly used Resuscitation equipment near bedside including bedside procedure carts
      4. Keep a Running code log of interventions visible to all (e.g. white board)
  5. References
    1. Herbert et al in Herbert (2016) EM:Rap 16(3): 5-6
    2. Swaminathan and Hicks in Herbert (2019) EM:Rap 19(12): 8-9
    3. Swaminathan, Petrosoniak and Hicks in Herbert (2021) EM:Rap 21(9): 4-6

VI. Approach: Pronouncement of Death (in the Field or Emergency Department

  1. Specific circumstances
    1. Ventricular Fibrillation or Ventricular Tachycardia (shockable rhythms)
      1. Most likely to identify a reversible cause and to respond to Resuscitation efforts
      2. Maintain high quality CPR
      3. Consider transport to ECMO or cath lab if refractory Ventricular Fibrillation or Ventricular Tachycardia
    2. Asystole
      1. Indications to continue efforts
        1. Initial rhythm of Asystole in unwitnessed arrest without obvious signs of death
      2. Indications to cease efforts
        1. Persistent Asystole for >20 minutes of Resuscitation efforts (Neuro intact survival <1%)
    3. Pulseless Electrical Activity (PEA)
      1. Indications to continue efforts
        1. Heart Rate >40-60 per minute
        2. End-Tidal CO2 trending >20
      2. Indications to cease efforts
        1. Point-Of-Care Ultrasound without cardiac activity
        2. End-Tidal CO2 persistently 5-10 or less for 20-25 minutes despite Resuscitation
        3. Persistent PEA for >60 minutes of Resuscitation efforts (Neuro intact survival <2%)
        4. Age alone does not impact decision to continue Resuscitation
    4. Obesity and pseudo-PEA
      1. Obese patients are at high risk for Pseudo-EMD (pulses not palpable due to Obesity)
      2. Consider empiric IV fluid bolus (and Vasopressor) if Pseudo-EMD suspected
      3. EMS should transport for bedside Echocardiogram for cardiac standstill if in doubt
      4. Allow for adequate Resuscitation efforts before pronouncement
        1. Duration of code until ROSC is >20 minutes in 25% of Cardiac Arrest cases
        2. Goldberger (2012) Lancet 380(9852): 1473-81 [PubMed]
    5. Prolonged Resuscitation
      1. Consider ceasing Resuscitation efforts after >45 to 55 minutes of high quality CPR, ACLS
      2. Low likelihood of good neurologic outcomes with prolonged Resuscitation
        1. Witnessed arrest with maintained high quality CPR to ECMO may warrant continued efforts
    6. Low Baseline Quality of Life (e.g. Advanced Dementia, end-stage COPD, CHF, metastatic cancer)
      1. Those who survive Cardiac Arrest will have a lower quality of life than before the arrest
      2. Discuss with family or other POA when considering Stopping Resuscitation efforts
    7. Pediatric death pronouncements
      1. All cases are referred to medical examiner cases and are investigated by police
  2. Criteria (all three together predict nearly 0% chance of survival)
    1. No Return of Spontaneous Circulation (ROSC) prior to transport AND
    2. Cardiac Arrest was not witnessed AND
    3. Rhythm was not shockable
    4. Morrison (2009) Resuscitation 80(3): 324-8 [PubMed]
  3. References
    1. Braude and Myers in Herbert (2016) EM:Rap 16(2): 18-9
    2. Shinar and Swadron in Herbert (2013) EM:Rap 13(3): 4-5
    3. Weingart and Swaminathan in Swadron (2022) EM:Rap 22(1): 3-5

VII. 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

VIII. 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
  4. Trauma points (Primary Survey Airway Evaluation )
    1. Is the patient speaking or vocalizing?
    2. Observe for foreign bodies, dentures and facial deformities interfering with airway maintenance
    3. Primary Survey Disability Evaluation (brief Neurologic Exam)
      1. Also described below as the D-part of the ABCDE Trauma algorithm
      2. Can be performed with airway (GCS, pupils and motor in all extremities)
      3. Critical to perform with airway if Rapid Sequence Intubation (RSI) or Conscious Sedation administered

IX. 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
  6. Trauma points (Primary Survey Breathing Evaluation)
    1. Palpate the chest for deformities, Flail Chest or open wounds
    2. Breath sounds are most useful when absent
      1. Treat asymmetrically absent breath sounds as a Pneumothorax
      2. Presence of breath sounds does not exclude Pneumothorax

X. 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)
  5. Trauma Points (Primary Survey Circulation Evaluation)
    1. See Primary Survey Circulation Evaluation
    2. Warm feet are a reassuring sign (cold feet might suggest shock state)
    3. Palpate the Abdomen for distention or signs of injury (source of occult bleeding)
    4. Compress the Pelvis by pushing both iliac crests together with force
      1. Assess for anterior or posterior Pelvis injury
      2. If the Pelvis moves inward on compression
        1. Hold this position and apply a Pelvic Binder for stabilization
        2. Do not repeat this exam in an unstable Pelvis

XI. Management: Trauma Disability Points (Primary Survey Disability Evaluation)

  1. May be performed simultaneously with the airway evaluation above
  2. Glasgow Coma Scale
  3. Pupil Reaction
  4. Can patient move all extremities?
    1. In Trauma, do not paralyze and intubate the patient prior to assessing for Spinal Cord Injury with paralysis

XII. Management: Trauma Exposure Points (Primary Survey Exposure Evaluation)

  1. All clothing should be removed to completely assess for injuries
  2. Exposure Penetrating Trauma first
  3. Mnemonic: Armpits, Back, Butt cheeks and Sac
    1. Assess for easily missed sites of injury
  4. Apply warm blankets

XIII. Management: Trauma - Additional Points

  1. Fast and Glucose/Girl (F and G in the Trauma ABCDEFG)
    1. Perform FAST Exam (Ultrasound)
    2. Check Serum Glucose
    3. Check serum or Urine Pregnancy Test
  2. Spine Precautions
    1. Backboard may be discontinued when Primary Survey completed
    2. Even with Spinal Injury, Backboard risks are much greater than benefit and should be removed soon after arrival
  3. Imaging
    1. CT Head
      1. Indicated for signs of Head Injury (especially if anticoagulated, Intoxication)
      2. See Head Injury CT Indications in Adults
      3. See Head Injury CT Indications in Children (PECARN)
    2. CT C-Spine
      1. Indicated for any ill patient who needs spine imaging (replaces Cross Table lateral XRay)
      2. See Cervical Spine Imaging in Acute Traumatic Injury (e.g. NEXUS Criteria)
    3. Chest XRay for all Trauma patients
    4. CT Abdomen and Pelvis
      1. May skip if benign Abdomen and Pelvis without pain, tenderness and if vitals signs stable

XIV. 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)
    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]

XV. 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. Start at 120 joules for biphasic Defibrillator or 50 Joules for monophasic Defibrillator
        1. Paroxysmal Supraventricular Tachycardia (PSVT)
        2. Atrial Flutter
      2. Start at 150 joules for biphasic Defibrillator or 100 Joules for monophasic Defibrillator
        1. Atrial Fibrillation
        2. Monomorphic Ventricular Tachycardia
      3. Start at 200 joules for biphasic Defibrillator or 360 Joules for monophasic Defibrillator
        1. Polymorphic Ventricular Tachycardia (Unsynchronized Shock will likely be required)
    4. Children
      1. Initial: 0.5 to 1 J/kg
      2. Refractory: 2 J/kg

XVI. 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

XVII. 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. 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
        2. Synchronized Cardioversion
        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)

XVIII. Management: Rhythm - Pulse Present - Stable - Tachycardia in Children (PALS)

  1. Indicated if unstable criteria above not met
  2. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  3. Wide Complex Tachycardia (QRS wider than 0.09 msec; contrast with 0.12 in adults)
    1. Consider Ventricular Tachycardia
    2. Unstable Wide Complex Tachycardia
      1. See Unstable Tachycardia above
      2. Synchronized Cardioversion
    3. Stable, regular Wide Complex Tachycardia
      1. Consider SVT with aberrancy if monomorphic QRS and regular rhythm
      2. Adenosine
        1. Do not use Adenosine if rhythm irregular (risk of WPW or rhythm degeneration)
        2. First: 0.1 mg/kg (maximum 6 mg)
        3. Second: 0.2 mg/kg (maximum 12 mg)
    4. Stable, irregular or refractory Wide Complex Tachycardia
      1. Precautions
        1. Consult cardiology about recommended Antiarrhythmic
        2. Avoid combining Amiodarone and Procainamide
      2. Agents
        1. Amiodarone 5 mg/kg over 20-60 minutes
        2. Procainamide 15 mg/kg IV over 30-60 minutes
  4. Narrow Complex Tachycardia (QRS 0.09 msec or less; contrast with 0.12 in adults)
    1. Sinus Tachycardia
      1. Findings
        1. Normal P Waves, variable R-R with a constant PR Interval
        2. Heart Rate <180 in children (<220 in infants)
      2. See Sinus Tachycardia
      3. Indentify and treat underlying cause
    2. Supraventricular Tachycardia
      1. Findings
        1. Abnormal or absent P Waves
        2. Constant Heart Rate >180 in children (>220 in infants)
      2. Vagal Maneuvers if no delays
      3. Adenosine (if regular rhythm)
        1. Do not use Adenosine if rhythm irregular (risk of WPW or rhythm degeneration)
        2. First: 0.1 mg/kg (maximum 6 mg)
        3. Second: 0.2 mg/kg (maximum 12 mg)
      4. Synchronized Cardioversion
        1. Indicated for irregular rapid rhythm or SVT refractory to above measures

XIX. 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

XX. Resources

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

XXI. 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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Related Studies

Ontology: Cardiopulmonary Resuscitation (C0007203)

Definition (MEDLINEPLUS)

When someone's blood flow or breathing stops, seconds count. Permanent brain damage or death can happen quickly. If you know how to perform cardiopulmonary resuscitation (CPR), you could save a life. CPR is an emergency procedure for a person whose heart has stopped or is no longer breathing. CPR can maintain circulation and breathing until emergency medical help arrives.

Even if you haven't had training, you can do "hands-only" CPR for a teen or adult whose heart has stopped beating ("hands-only" CPR isn't recommended for children). "Hands-only" CPR uses chest compressions to keep blood circulating until emergency help arrives. If you've had training, you can use chest compressions, clear the airway, and do rescue breathing. Rescue breathing helps get oxygen to the lungs for a person who has stopped breathing. To keep your skills up, you should repeat the training every two years.
Definition (CSP) the artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes; the two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage.
Definition (MSH) The artificial substitution of heart and lung action as indicated for HEART ARREST resulting from electric shock, DROWNING, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation (RESPIRATION, ARTIFICIAL) and closed-chest CARDIAC MASSAGE.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D016887
ICD9 99.60
ICD10 92052-00
SnomedCT 182610000, 150819003, 89666000
CPT 92950
English Cardio Pulmonary Resuscitation, Cardio-Pulmonary Resuscitation, CPR, Resuscitation, Cardio-Pulmonary, heart resuscitation, CARDIOPULMONARY RESUSCITATION, Resuscitation, Cardiopulmonary, CPR - Cardiopulm resuscitation, CARDIOPULM RESUSCITATION, CARDIO PULM RESUSCITATION, CPR (cardiopulmonary resuscitation), cardiopulmonary resuscitation (treatment), cardiopulmonary resuscitation, Cardiopulm resuscita NOS, Cardiopulmonary resuscitation (eg, in cardiac arrest), Compression;chest;heart, cardio-pulmonary resuscitation, cardiopulmonary resuscitation (CPR), Cardiopulmonary Resuscitation, Cardiopulmonary resuscitation (& closed cardiac massage & ventilation) (procedure), Closed cardiac massage+ventil., Cardiopulmonary resuscitation (& closed cardiac massage & ventilation), CPR - Cardiopulmonary resuscitation, Cardiopulmonary resuscitation, Cardiopulmonary resuscitation (procedure), Cardiopulmonary resuscitation, NOS, HEART/LUNG RESUSCITATION CPR, Heart/lung resuscitation cpr, Cardiopulmonary resuscitation, not otherwise specified
Swedish Hjärt-lungräddning
Czech kardiopulmonální resuscitace
Finnish Puhallus-paineluelvytys
Russian ROT V ROT REANIMATSIIA, REANIMATSIIA PO SPOSOBU ROT V ROT, KARDIOPUL'MONAL'NAIA REANIMATSIIA, SERDECHNO-LEGOCHNAIA REANIMATSIIA, КАРДИОПУЛЬМОНАЛЬНАЯ РЕАНИМАЦИЯ, РЕАНИМАЦИЯ ПО СПОСОБУ РОТ В РОТ, РОТ В РОТ РЕАНИМАЦИЯ, СЕРДЕЧНО-ЛЕГОЧНАЯ РЕАНИМАЦИЯ
Japanese マウス･ツー･マウス人工呼吸法, 人工呼吸-口対口, 心肺蘇生術, 口対口人工呼吸法, 心肺蘇生法, 口-口人工呼吸法
French RCP (Réanimation CardioPulmonaire), Réanimation cardiorespiratoire, RCR (Réanimation CardioRespiratoire), Réanimation cardio-pulmonaire, Réanimation cardiopulmonaire
Italian CPR, Rianimazione cardiopolmonare
Polish Podstawowe zabiegi resuscytacyjne, CPR, Resuscytacja krążeniowo-oddechowa
Croatian KARDIOPULMONALNA REANIMACIJA
Norwegian Hjerte-lunge-redning, CPR, HLR
Spanish Reanimación Cardiopulmonar, Respiración Boca a Boca, Reanimación Cardiopulmonar Básica, RCP, reanimación cardiopulmonar (procedimiento), reanimación cardiopulmonar, CPR, Resucitación Cardiopulmonar
Portuguese Manutenção das Condições Vitais Cardíacas Básicas, Reanimação Cardiopulmonar, Suporte das Condições Vitais Cardíacas Básicas, Respiração Boca-a-Boca, CPR, Ressuscitação Cardiopulmonar
German CPR, Kardiopulmonale Reanimation, Kardiopulmonale Wiederbelebung, Herz-Lungen-Wiederbelebung
Dutch CPR, Resuscitatie, cardiopulmonale
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Cardiac Arrest (C0018790)

Definition (MSHCZE) Zastavení srdečního rytmu nebo stahů (MYOKARD – KONTRAKCE). Je-li srdeční činnost obnovena během několika minut, může být srdeční zástava ve většině případů bez následků obrácena zpět do normálního srdečního rytmu a tím i krevního oběhu. R
Definition (MEDLINEPLUS)

The heart has an internal electrical system that controls the rhythm of the heartbeat. Problems can cause abnormal heart rhythms, called arrhythmias. There are many types of arrhythmia. During an arrhythmia, the heart can beat too fast, too slow, or it can stop beating. Sudden cardiac arrest (SCA) occurs when the heart develops an arrhythmia that causes it to stop beating. This is different than a heart attack, where the heart usually continues to beat but blood flow to the heart is blocked.

There are many possible causes of SCA. They include coronary heart disease, physical stress, and some inherited disorders. Sometimes there is no known cause for the SCA.

Without medical attention, the person will die within a few minutes. People are less likely to die if they have early defibrillation. Defibrillation sends an electric shock to restore the heart rhythm to normal. You should give cardiopulmonary resuscitation (CPR) to a person having SCA until defibrillation can be done.

If you have had an SCA, an implantable cardiac defibrillator (ICD) reduces the chance of dying from a second SCA.

NIH: National Heart, Lung, and Blood Institute
Definition (NCI_CDISC) Cardiac arrest is the non-fatal, sudden cessation of cardiac activity so that the victim subject/patient becomes unresponsive, with no normal breathing and no signs of circulation. Cardiac arrest should be used to signify an event as described above that is reversed, usually by CPR, and/or defibrillation or cardioversion, or cardiac pacing.
Definition (NCI_CTCAE) A disorder characterized by cessation of the pumping function of the heart.
Definition (NCI_FDA) Sudden cessation of the pumping function of the heart, with disappearance of arterial blood pressure, connoting either ventricular fibrillation or ventricular standstill.
Definition (NCI) The sudden cessation of cardiac activity in an individual who becomes unresponsive, without normal breathing and no signs of circulation. Cardiac arrest may be reversed by CPR, and/or defibrillation, cardioversion or cardiac pacing.
Definition (CSP) cessation of the heart beat.
Definition (MSH) Cessation of heart beat or MYOCARDIAL CONTRACTION. If it is treated within a few minutes, heart arrest can be reversed in most cases to normal cardiac rhythm and effective circulation.
Concepts Disease or Syndrome (T047)
MSH D006323
ICD9 427.5
ICD10 I46 , I46.9
SnomedCT 251189000, 30298009, 309810002, 195085006, 195090009, 397912004, 155372006, 397829000, 410429000
LNC LP133247-9, MTHU041449, LA17068-0, LA17496-3, LA9535-1
English Arrest, Heart, Asystole, Asystoles, Heart Arrest, ASYSTOLIA, Arrest, Cardiac, VENTRICULAR ASYSTOLIA, Cardiac arrest - asystole, Cardiac arrest, unspecified, CA - Cardiac arrest, Cardiac Arrest, cardiac arrest, cardiac arrest (diagnosis), asystole (diagnosis), asystole, Arrest cardiac, Heart arrest, Ventricular asystole, Asystolia, Ventricular asystolia, Asystolic, Standstill cardiac, Heart Arrest [Disease/Finding], arrest [as an cardiac arrest], asystolia, ventricular asystole, cardiac asystole, heart arrest, arrest, arrested, Cardiac arrest, unspecified (disorder), Asystole (finding), SCA, ASYSTOLE, ARREST, CARDIAC, CARDIAC ARREST, Cardiac arrest- asystole, Cardiac standstill, Asystole (disorder), heart; arrest, heart; stoppage, stoppage; heart, ventricular; arrest, arrest; cardiac, arrest; ventricular, Cardiac arrest, Cardiac arrest (disorder)
French ARRET CARDIAQUE, Asystolie, Arrêt des contractions du coeur, Asystole ventriculaire, Asystolique, Arrêt du coeur, Asystole, ASYSTOLIE VENTRICULAIRE, ASYSTOLIE, Pause cardiaque, Arrêt cardiaque, Arrêt cardio-circulatoire, Arrêt cardiocirculatoire
Portuguese PARADA CARDIACA, Assístolia, Assistólico, ASSISTOLIA VENTRICULAR, ASSISTOLIA, Parada Cardiorrespiratória, Paralisia Cardíaca, Assistolia ventricular, Paragem cardíaca, Assistolia, Parada Cardíaca
Spanish PARO CARDIACO, ASISTOLIA, Asistólico, Paro cardiaco, Asístole, Parada Cardíaca, ASISTOLIA VENTRICULAR, paro cardíaco, no especificado, paro cardíaco, no especificado (trastorno), asístole, Cardiac arrest, unspecified, Parada Cardiorrespiratoria, Parálisis Cardíaca, Parada Cardiopulmonar, Paro Cardiorrespiratorio, asistolia (trastorno), asistolia, Asistolia ventricular, Parada cardiaca, paro cardíaco (trastorno), paro cardíaco, Asistolia, Paro Cardíaco
German HERZSTILLSTAND, Asystolisch, Stillstand Herz, ASYSTOLIE, Herzstillstand, nicht naeher bezeichnet, VENTRIKULAERE ASYSTOLIE, ventrikulaere Asystolie, Asystolie, Herzstillstand, Kardialer Stillstand
Italian Asistole ventricolare, Asistolico, Asistolia, Asistolia ventricolare, Asistole, Arresto cardiaco
Dutch asystolie, ventriculaire asystolie, stilstand van het hart, asystole, asystolisch, hart; stilstand, hart; stoppen, stilstand; hart, stilstand; ventriculair, stoppen; hart, ventriculair; stilstand, Hartstilstand, niet gespecificeerd, hartstilstand, ventriculaire asystole, Arrest, cardiaal, Asystolie, Hartstilstand, Stilstand, hart-
Japanese 心室無収縮, ｼﾝｼﾂﾑｼｭｳｼｭｸ, ｼﾝﾃｲｼ, 心肺停止, 心拍停止, 不全収縮期, ｼﾝｾｲｼ, 心静止, 心臓停止, 心停止
Swedish Hjärtstopp
Czech srdce - zástava, Srdeční zástava, Asystolie, Zástava srdce, Komorová asystolie, asystolie
Finnish Sydämenpysähdys
Russian ASISTOLIIA, SERDTSA OSTANOVKA, SERDTSA I DYKHANIIA OSTANOVKA, АСИСТОЛИЯ, СЕРДЦА И ДЫХАНИЯ ОСТАНОВКА, СЕРДЦА ОСТАНОВКА
Korean 심장정지, 상세불명의 심장정지
Croatian SRČANI ZASTOJ
Polish Zatrzymanie czynności serca, Asystolia, Nagłe zatrzymanie krążenia, Zatrzymanie akcji serca
Hungarian Ventricularis asystole, Asystole, Asystoliás, Szívmegállás, Szív nem működik, Asystolia, Szív megállása, Cardialis leállás, Ventricularis asystolia
Norwegian Hjertestans, Hjertestopp, Asystoli
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Resuscitation procedure (C0035273)

Definition (NCI) The measures applied for the restoration a person to life and/or consciousness. The act of resuscitation includes such components as artificial respiration and cardiac massage.
Definition (MSH) The restoration to life or consciousness of one apparently dead. (Dorland, 27th ed)
Definition (CSP) restoration to life or consciousness.
Definition (NIC) Administering emergency measures to sustain life
Concepts Therapeutic or Preventive Procedure (T061)
MSH D012151
SnomedCT 439569004
English Resuscitation, Resuscitations, Resuscitation (procedure), Resuscitation procedure, resuscitation
Japanese 蘇生法, ｿｾｲﾎｳ
Swedish Återupplivning
Czech kříšení, resuscitace, Resuscitace
Finnish Elvytys
Russian REANIMATSIIA, РЕАНИМАЦИЯ
French Ressuscitation, Réanimation
Spanish reanimación, reanimación (procedimiento), Resucitación
Croatian REANIMACIJA
Polish Resuscytacja, Ożywianie
Hungarian Resuscitatio
Norwegian Gjenopplivning, Livredning
Portuguese Reanimação, Ressuscitação
Dutch reanimatie, Reanimatie, Resuscitatie
German Reanimation, Wiederbelebung
Italian Rianimazione
Derived from the NIH UMLS (Unified Medical Language System)

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