Contents · 12 sections
- 1. Chain of Survival
- 2. BLS — Basic Life Support
- 3. ACLS — Advanced Cardiovascular Life Support
- 4. 4H and 4T — Reversible Causes
- 5. Defibrillation
- 6. Airway Management and Ventilation
- 7. Vascular/Intraosseous Access
- 8. Medications
- 9. Special Situations
- 10. Post-Resuscitation Care
- 11. Criteria for Terminating CPR
- 12. FAQ
In a nutshell. Initial actions for cardiac arrest (BLS): check safety, responsiveness, and breathing; call for help + retrieve an AED; start chest compressions at 100–120/min, depth 5–6 cm, ratio 30:2; as soon as an AED is available — rhythm analysis and shock if indicated. In ACLS: epinephrine 1 mg every 3–5 min for any rhythm; amiodarone 300 mg (or lidocaine) for shockable rhythms after the 3rd shock; correction of reversible causes (4H/4T: hypoxia, hypovolemia, hypo-/hyperkalemia, hypothermia; tension pneumothorax, cardiac tamponade, toxins, thrombosis). High-quality chest compressions with minimal interruptions are more important than any medications.
1. Chain of Survival
- Early recognition of cardiac arrest and calling for help.
- Early high-quality chest compressions.
- Early defibrillation.
- Advanced life support and post-resuscitation care.
- Recovery — rehabilitation.
Every minute without defibrillation in VF/VT decreases survival by 7–10 %.
2. BLS — Basic Life Support
Adult algorithm
- Check scene safety.
- Assess responsiveness: "Are you okay?", tap gently on the shoulders.
- Call for help (112 / emergency team), ask to bring an AED.
- Open the airway (head-tilt/chin-lift).
- Check breathing for no more than 10 sec (look, listen, feel). Agonal gasps = cardiac arrest!
- Start chest compressions: 30 : 2 (compressions : breaths), rate 100–120/min, depth 5–6 cm, full chest recoil between compressions.
- Breaths: 1 sec, visible chest rise; if impossible — continuous chest compressions (hands-only CPR).
- AED: turn on, apply pads, follow voice prompts; after a shock — immediately resume chest compressions.
- Switch compressor every 2 min (5 cycles of 30 : 2) without interrupting compressions.
- Continue until the ACLS team arrives or return of spontaneous circulation (ROSC).
Quality of chest compressions
- Rate 100–120/min (rhythm — "Stayin' Alive").
- Depth 5–6 cm (at least 5, no more than 6).
- Full chest recoil.
- Minimum interruptions (< 10 sec), chest compression fraction > 60 %.
- Switch roles every 2 min when two rescuers are present.
3. ACLS — Advanced Cardiovascular Life Support
Shockable rhythms (VF/pulseless VT)
- Compressions for 2 min, prepare defibrillator.
- Shock (biphasic 120–200 J; monophasic 360 J).
- Immediately — compressions for 2 min, without pulse check.
- Rhythm check; if VF/VT persists — shock + 2 min of compressions.
- Epinephrine 1 mg IV/IO after the 2nd shock, then every 3–5 min.
- Amiodarone 300 mg IV after the 3rd shock; if VF persists — second dose of 150 mg.
- Alternative — lidocaine 1–1.5 mg/kg, then 0.5–0.75 mg/kg.
- Establish advanced airway management, capnography.
- Treat reversible causes (4H/4T).
Non-shockable rhythms (asystole, PEA)
- Continuous compressions for 2 min.
- Epinephrine 1 mg IV/IO as soon as possible, then every 3–5 min.
- Identify and correct reversible causes.
- Rhythm check every 2 min.
4. 4H and 4T — Reversible Causes
| «H» | What to look for | How to treat |
|---|---|---|
| Hypoxia | SpO₂, blood gas analysis, correct tube placement | 100% O₂, check ventilation, capnography |
| Hypovolemia | Bleeding, medical history | Crystaloid bolus 1–2 L, stop bleeding, transfusion |
| Hypo/hyperkalemia, metabolic | K⁺, pH, glucose | Ca²⁺ gluconate, bicarbonate, insulin + glucose; correction of acidosis |
| Hypothermia | < 35 °C | Active warming; if < 30 °C — 1 shock, delay medications |
| «T» | What to look for | How to treat |
|---|---|---|
| Tension pneumothorax | Unilateral absence of breath sounds, tracheal deviation | Emergency needle decompression in the 2nd intercostal space at the midclavicular line |
| Tamponade | Beck's triad, ultrasound — effusion | Ultrasound-guided pericardiocentesis |
| Toxins | History, signs of ingestion | Antidote (naloxone for opiates, lipid emulsion for local anesthetics, bicarbonate for tricyclic antidepressants) |
| Thrombosis (MI, PE) | ECG, clinical assessment for PE | Thrombolysis with tPA for PE + continuation of CPR ≥ 60–90 min |
5. Defibrillation
- Early defibrillation is the primary survival factor in VF/VT.
- Biphasic 120–200 J (first shock), then escalation; monophasic 360 J.
- Pad placement: anterolateral (right subclavian + left mid-axillary) or anteroposterior.
- Rhythm check every 2 min, 1 shock for a shockable rhythm.
- Continue chest compressions while the defibrillator is charging.
6. Airway management and ventilation
- In BLS — bag-mask device, 10 breaths/min with an advanced airway.
- Supraglottic airway devices (LMA, i-gel) as an alternative to intubation.
- Intubation — if experienced, with minimal interruption of chest compressions (< 10 sec).
- Capnography (EtCO₂): < 10 mm Hg — poor prognosis; sharp ↑ → likely return of spontaneous circulation.
7. Vascular/intraosseous access
- Preferably peripheral IV; if unsuccessful — intraosseous (IO).
- Endotracheal administration — not recommended (low bioavailability).
- Central line access — only if already established or by experienced personnel, without interrupting chest compressions.
8. Medications
- Epinephrine 1 mg IV/IO every 3–5 min — for shockable rhythms given after the 2nd shock, for non-shockable — immediately.
- Amiodarone 300 mg IV in VF/VT after the 3rd shock; second dose 150 mg.
- Lidocaine 1–1.5 mg/kg — alternative to amiodarone.
- Magnesium sulfate 2 g for torsades de pointes.
- Sodium bicarbonate — only for hyperkalemia, tricyclic antidepressant overdose, prolonged resuscitation.
- Calcium gluconate — hyperkalemia, hypocalcemia, calcium channel blockers.
- Atropine — no longer recommended for asystole.
- Naloxone — for opiate overdose.
9. Special situations
Pregnancy
- Left uterine displacement (manually or manual lateral tilt) to relieve inferior vena cava compression.
- Chest compressions slightly higher than usual.
- Perimortem Cesarean delivery within 5 min if CPR is unsuccessful and gestational age > 20 weeks.
Pediatrics
- 15 : 2 for two rescuers (children and infants); 30 : 2 for a single rescuer.
- Infants: two-finger technique or two-thumb encircling hands technique.
- Depth 1/3 of the anteroposterior chest diameter.
- Epinephrine 0.01 mg/kg IV/IO every 3–5 min.
- Defibrillation: 2 J/kg → 4 J/kg.
Hypothermia
- < 30 °C: 1 shock, then warm up; delay medications until > 30 °C.
- 30–35 °C: medications every 6–10 min.
- "Not dead until warm and dead" — prolonged resuscitation in cold water drowning.
- ECMO/CPB if T < 30 °C and cardiac arrest persists.
10. Post-resuscitation care
- Target SpO₂ 94–98 %, EtCO₂ 35–40 mm Hg, SBP ≥ 65 mm Hg.
- 12-lead ECG; emergency PCI for STEMI.
- Targeted temperature management (TTM): 32–36 °C for 24 h in comatose patients.
- Seizure prophylaxis, glucose control, sedation.
- Prognosis — no earlier than 72 h (with TTM — 72 h after normothermia), comprehensive assessment (EEG, neuron-specific enolase, MRI, clinical exam).
11. Criteria for termination of CPR
- Return of spontaneous circulation (ROSC).
- Objective signs of biological death.
- No effect for ≥ 30 min despite proper resuscitation and absence of reversible causes.
- DNR order, terminal illness.
- Exceptions: hypothermia, poisonings, pulmonary embolism, children — prolonged resuscitation is justified.
12. FAQ
Why are chest compressions more important than breaths?
Without blood flow, the brain dies in 4–6 min. Blood oxygen saturation persists for some time; the priority is circulation. Hands-only CPR is nearly equivalent in witnessed cardiac arrest in adults.
How to avoid fatigue during CPR?
Switch rescuer every 2 min. Fatigue means losing depth. During solo resuscitation, a brief slowdown is acceptable to recover.
When to perform intubation?
Without interrupting compressions, if experienced and equipped. Supraglottic devices are often no worse than intubation during cardiac arrest.
What is capnography during CPR?
EtCO₂ < 10 mm Hg after 20 min indicates a low probability of ROSC. A sharp increase (> 35–40) is a sign of ROSC without the need to interrupt compressions.
Is routine bicarbonate needed?
No. Indicated in hyperkalemia, TCA overdose, prolonged resuscitation > 10–15 min with confirmed acidosis. Routine administration does not improve outcomes.
See also: Myocardial infarction · Arrhythmias · Anaphylaxis · Stroke · Emergency Guide