Cardiac arrest remains one of the most critical emergencies encountered in healthcare. It is the sudden cessation of effective cardiac mechanical activity, leading to loss of circulation and, if not promptly treated, death. Advanced Cardiac Life Support (ACLS) provides a structured, evidence-based approach to resuscitation, improving the chances of return of spontaneous circulation (ROSC) and survival with good neurological outcomes.
Understanding Cardiac Arrest
Cardiac arrest occurs when the heart stops pumping blood effectively. The underlying rhythm may be shockable or non-shockable:
Shockable rhythms: Ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT)
Non-shockable rhythms: Asystole and pulseless electrical activity (PEA)
Recognizing the rhythm type early is essential, as it determines the immediate steps in the ACLS algorithm.
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The ACLS Cardiac Arrest Algorithm (Step-by-Step)
1. Immediate Response
If cardiac arrest is suspected:
Check responsiveness and assess breathing and pulse within 10 seconds.
If no pulse and no breathing (or gasping only), activate the emergency response system and start high-quality CPR immediately.
Attach a defibrillator or monitor as soon as available.
2. CPR Basics
Compression rate: 100–120/min
Depth: 5–6 cm (2–2.4 inches)
Allow full recoil between compressions
Minimize interruptions, keeping pauses under 10 seconds
Ventilations: 2 breaths after every 30 compressions (30:2 ratio)
If advanced airway is in place: Give continuous compressions with 1 breath every 6 seconds (10 breaths per minute).
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3. Rhythm Check and Defibrillation
After 2 minutes (5 cycles) of CPR:
Check rhythm quickly.
If shockable (VF/pVT):
Deliver one shock (biphasic 120–200 J or monophasic 360 J).
Immediately resume CPR for 2 minutes after the shock — do not check pulse yet.
After 2 minutes, reassess rhythm.
If still shockable, repeat shock and continue CPR.
If non-shockable (asystole/PEA):
Continue CPR for 2 minutes and reassess rhythm.
Do not shock. Focus on medications and identifying reversible causes.
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4. Medications in Cardiac Arrest
Medications are integrated into CPR cycles once IV or IO access is established:
Epinephrine: 1 mg IV/IO every 3–5 minutes during CPR (for both shockable and non-shockable rhythms).
Amiodarone (for shockable rhythms):
First dose: 300 mg IV/IO bolus
Second dose: 150 mg IV/IO if VF/pVT persists
If amiodarone is unavailable, lidocaine can be used (1–1.5 mg/kg initial dose, followed by 0.5–0.75 mg/kg as needed).
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5. Airway and Oxygen Management
Effective oxygenation and ventilation are vital:
Provide 100% oxygen initially.
Avoid hyperventilation — excessive ventilation increases intrathoracic pressure, reducing venous return and cardiac output.
Use advanced airway (ET tube or supraglottic device) when trained personnel are available, but do not delay chest compressions for intubation.
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6. Identifying Reversible Causes – The H’s and T’s
A major focus during ACLS is identifying treatable causes of cardiac arrest. These are summarized as:
The 5 H’s:
1. Hypoxia
2. Hypovolemia
3. Hydrogen ion (acidosis)
4. Hypo-/Hyperkalemia
5. Hypothermia
The 5 T’s:
1. Tension pneumothorax
2. Tamponade (cardiac)
3. Toxins (drug overdose, poisoning)
4. Thrombosis (pulmonary embolism)
5. Thrombosis (myocardial infarction)
Reversing these underlying causes can often restore spontaneous circulation when standard interventions fail.
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7. Return of Spontaneous Circulation (ROSC)
Once ROSC is achieved:
Begin post-cardiac arrest care immediately.
Maintain oxygen saturation 94–99%.
Monitor and control blood pressure (target systolic ≥ 90 mmHg, MAP ≥ 65 mmHg).
Manage temperature — consider targeted temperature management (TTM) for comatose patients.
Identify and treat underlying cause (e.g., acute coronary syndrome, electrolyte disturbance).
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8. Key Principles for Success
Early defibrillation for shockable rhythms saves lives.
High-quality CPR is the foundation of ACLS — poor compressions drastically reduce outcomes.
Minimal interruptions between CPR and defibrillation improve survival.
Team coordination and clear communication are essential during resuscitation.
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Final Thoughts
The ACLS cardiac arrest algorithm is more than a protocol — it’s a structured approach that combines science, teamwork, and rapid decision-making to save lives. Every healthcare provider should be proficient in its steps, understanding not just what to do but why each action matters. Continuous training, mock codes, and real-time feedback during CPR can dramatically improve patient outcomes and confidence during true cardiac emergencies.
Keywords: ACLS, cardiac arrest, CPR, advanced cardiac life support, defibrillation, resuscitation, emergency medicine, epinephrine, amiodarone, ROSC
Hashtags: #ACLS #CardiacArrest #CPR #EmergencyMedicine #CriticalCare #Resuscitation #Cardiology
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