Advanced Cardiac Life Support (ACLS): Adult Cardiac Arrest 

Updated: May 10, 2018
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
  • Print

Advanced Cardiac Life Support (ACLS): Adult Cardiac Arrest

ACLS: Adult Arrest

1. The initial evaluation is as follows: [1, 2, 3, 4]

  • Activate emergency response system.
  • Initiate adult basic life support (BLS) algorithm.

2. The initial intervention is as follows:

  • Start high-quality cardiopulmonary resuscitation (CPR).
  • Administer oxygen if hypoxemic.
  • Attach monitor/defibrillator.
  • Monitor blood pressure and oximetry; do not delay defibrillation.

3. Check rhythm, as follows:

  • Shockable rhythm = Ventricular fibrillation or pulseless ventricular tachycardia (VF/VT)
  • Nonshockable rhythm = Asystole/pulseless electrical activity (PEA)

Shockable Rhythm

1. Initial treatment of VT/VF is as follows:

  • Defibrillate immediately.
  • Continue CPR for 2 minutes.
  • Obtain intravenous (IV)/intraosseous (IO) access.
  • Consider advanced airway, end-tidal carbon dioxide tension (PETCO 2).

2. Administer vasopressor (epinephrine q3-5min)

3. Check pulse and rhythm every 2 minutes, as follows:

  • If nonshockable, see Nonshockable Rhythm (below).
  • If shockable, see Shockable Rhythm (above) and administer amiodarone after second defibrillation attempt.
  • Rotate chest compressors.
  • Identify and treat reversible causes.

4. If return of spontaneous circulation (ROSC), see ACLS: Post-Cardiac Arrest Care.

Nonshockable Rhythm

1. Initial treatment of asystole/PEA is as follows:

  • Continue CPR for 2 minutes.
  • Obtain intravenous (IV)/intraosseous (IO) access.
  • Consider advanced airway, end-tidal carbon dioxide tension (PETCO 2).

2. Administer vasopressor (epinephrine q3-5min).

3. Check pulse and rhythm every 2 minutes, as follows:

  • If nonshockable, see Nonshockable Rhythm (above).
  • If shockable, see Shockable Rhythm (above).
  • Rotate chest compressors.
  • Identify and treat reversible causes.

4. If return of spontaneous circulation (ROSC), see ACLS: Post-Cardiac Arrest Care

CPR Quality

See the list below:

  • Push hard and fast, at least 2 inches (5 cm) and 100-120 compressions per minute.
  • Allow complete chest recoil.
  • Minimize interruptions in compressions.
  • Avoid excessive ventilation.
  • Rotate compressor every 2 minutes or if fatigued.
  • Compression-to-ventilation ratio is 30:2.
  • Continuous compressions if advanced airway present
  • If PETCO 2 is less than 10 mm Hg, attempt to improve CPR quality (2010 recommendation, not specified in 2015).
  • If diastolic pressure is less than 20 mm Hg, attempt to improve CPR quality (2010 recommendation, not specified in 2015).

Shock Energy

See the list below:

  • Biphasic: Manufacturer recommendation (eg, 120-200 J initial); if unknown, use maximum available.
  • Monophasic: 360 J

Drug Therapy

See the list below:

  • Epinephrine 1 mg IV/IO q3-5min
  • Amiodarone 300 mg IV/IO initial dose, amiodarone 150 mg IV/IO second dose
  • Flush medications with 20 mL fluid after and elevate extremity for 10-20 seconds.
  • Combining medications is not recommended and may cause harm.
  • Routine use of sodium bicarbonate is not recommended and may cause harm (eg, if inadequate ventilation)
  • Routine use of magnesium for VF/VT is not recommended in adult patients.

Advanced Airway

See the list below:

  • Endotracheal tube (ETT) or supraglottic airway (SGA)
  • Waveform capnography to confirm and monitor ET tube placement
  • Ventilation every 6 seconds asynchronous with compressions
  • Stop CPR for no longer than 10 seconds for the placement of an advanced airway.

Return of Spontaneous Circulation

Signs of ROSC include the following:

  • Pulse and blood pressure present
  • Abrupt sustained increase in PETCO 2 (typically >40 mm Hg)
  • Spontaneous arterial pressure waves with intra-arterial monitoring

Reversible Causes (H’s and T’s)

See the list below:

  • H's: hypovolemia, hypoxia, H+ (acidosis), hypokalemia, hyperkalemia, hypothermia
  • T's: toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary, coronary)

Most Recent Guideline Changes

Changes from the 2010 guidelines include the following:

  • Simultaneous breathing and pulse check in less than 10 seconds
  • Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm.
  • Provide opioid overdose education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose
  • In pregnancy, if the fundus height is at or above the level of the umbilicus, manual left uterine displacement can be beneficial in relieving aortocaval compression during chest compression.

Changes from the 2010 ACLS guidelines: For simplicity, vasopressin has been removed from the adult algorithm.