CCM Notes
Emergency Medicine · Cardiac Arrest
ACLS Algorithm 2020
Shockable vs Non-shockable Rhythms · Drug Doses · Defibrillation · H's & T's
⚡ CPR Quality Standards (AHA 2020)
Compression Rate
100–120
/minute
Depth
2–2.4"
5–6 cm adults
Full Recoil
100%
Allow complete recoil
Interruptions
<10s
Min pause for rhythm check
Breaths
30:2
Until advanced airway
Ventilation (intubated)
10/min
Asynchronous with CPR
Vasopressor
Epi 1mg
IV/IO q3–5min
Shock check
Every 2 min
Before/after defibrillation
⚡ Shockable Rhythms
VF (Ventricular Fibrillation) & pVT (Pulseless VT)
1
CPR 2 min while charging → Shock ASAP
2
Defibrillate: 200J biphasic (or max); 360J monophasic
3
Resume CPR immediately × 2 min → recheck
4
Epinephrine 1 mg IV q3–5min (after 2nd shock)
5
If VF/pVT persists after 3rd shock: Amiodarone 300 mg IV (2nd: 150 mg) OR Lidocaine 1–1.5 mg/kg IV
6
After ROSC: targeted temperature management 32–36°C × 24h
Defibrillation Energy
Biphasic (Adult)
120–200 J
Per manufacturer (escalate)
Monophasic
360 J
All shocks
Pediatric
2–4 J/kg
Max 10 J/kg
🫀 Non-Shockable Rhythms
PEA (Pulseless Electrical Activity) & Asystole
1
CPR continuously × 2 min cycles
2
Epinephrine 1 mg IV q3–5min — as soon as possible
3
Advanced airway: intubate or SGA (do not interrupt CPR)
4
IV/IO access: isotonic crystalloid bolus
5
Treat reversible causes: H's & T's (see below)
6
If ROSC: 12-lead ECG, BP, end-tidal CO₂ monitoring; ETCO₂ >10 = effective CPR
End-Tidal CO₂ Monitoring
ETCO₂ <10 mmHg → improve CPR quality
ETCO₂ >40 mmHg → ROSC likely
Low ETCO₂ despite good CPR → consider stopping resuscitation
💊 ACLS Drug Doses
Drug
Dose
Indication / Notes
Epinephrine
1 mg IV q3–5min
All cardiac arrest; first ASAP in non-shockable
Amiodarone
300 mg IV; then 150 mg
VF/pVT refractory to 3 shocks
Lidocaine
1–1.5 mg/kg IV
Alternative to amiodarone VF/pVT
Magnesium
2 g IV push
Torsades de Pointes (TdP) only
Adenosine
6 mg → 12 mg IV (rapid push)
SVT with pulse; not for irregular/wide complex
Atropine
0.5 mg IV q3–5min (max 3mg)
Symptomatic bradycardia (not AV block)
Sodium Bicarb
1 mEq/kg IV
Hyperkalemia, TCA OD, severe metabolic acidosis
Calcium Chloride
0.5–1 g IV
Hyperkalemia, Ca-channel blocker OD, hypoCa
🔍 Reversible Causes — H's & T's
H's
Hypovolemia → IV fluids
Hypoxia → ventilation/airway
Hydrogen ion (acidosis) → bicarb
Hypo/hyperkalemia → K+ correction
Hypothermia → warming
T's
Tension pneumothorax → needle decompression
Tamponade (cardiac) → pericardiocentesis
Toxins (OD) → antidotes/dialysis
Thrombosis (PE) → thrombolytics/thrombectomy
Thrombosis (coronary) → STEMI → PCI
Post-ROSC Care
▸ 12-lead ECG → STEMI → emergent PCI
▸ TTM: 32–36°C × 24h (or fever prevention 36°C)
▸ SpO₂ 94–99% | PaCO₂ 35–45 mmHg
▸ Avoid hypotension: MAP ≥65 mmHg
▸ Head CT to exclude hemorrhage