Resuscitation - Advanced Life Support Cardiac Arrest

Related Subjects: |Adrenaline/Epinephrine |Atropine |Adult Resus:Acute Anaphylaxis |Adult Resus:Basic Life Support |Adult Resus: Advanced Life Support |Adult Resus: Obstetric Cardiac Arrest |Newborn/Child Resus: All |Acute Hypotension |Cardiogenic shock |Distributive Shock |Hypovolaemic or Haemorrhagic Shock |Obstructive Shock |Septic Shock and Sepsis |Shock (General Assessment) |Toxic Shock Syndrome |Resus:Bradycardia |Resus:Tachycardia |Resus:Hyperkalaemia |Resus:Post Resuscitation Algorithm |Resus:Acute Severe Asthma |Resus:Acute Haemorrhage

🚨 Advanced Life Support (ALS) — Adult Cardiac Arrest

❤️‍🔥 Core idea: ALS builds on high-quality BLS. The priorities are continuous effective CPR, early defibrillation for VF/pulseless VT, adrenaline at the correct point in the algorithm, and active treatment of reversible causes.
⚡ Rhythm first determines the pathway: shockable = VF / pulseless VT; non-shockable = PEA / asystole.

🔄 During CPR

• Ensure high-quality CPR: rate 100–120/min, depth 5–6 cm, full recoil, minimal interruptions.
• Plan actions before interrupting CPR: rhythm check, shock delivery, airway, drugs and role allocation.
• Give oxygen and ventilate effectively.
• Consider an advanced airway and use continuous waveform capnography if available.
• Once an advanced airway is in place, continue chest compressions without pausing for ventilation.
• Ventilate at about 10 breaths/min once an advanced airway is in place; avoid hyperventilation.
• Obtain IV access; use intraosseous access if IV access is difficult or delayed.
• Give drugs according to shockable or non-shockable algorithm.
• Actively look for and treat reversible causes: 4 Hs and 4 Ts.
• Use capnography to confirm tracheal tube placement and to monitor CPR quality. A sudden rise in ETCO₂ may suggest ROSC.

⚡ Cardiac Arrest Rhythms

⚡ Shockable Arrest: VF / Pulseless VT

⚡ VF and pulseless VT need defibrillation. The most important intervention is rapid shock delivery with minimal interruption to chest compressions.

• Start CPR immediately while the defibrillator is attached.
• Confirm rhythm during a brief pause: VF or pulseless VT.
• Charge defibrillator while compressions continue if safe to do so.
• Deliver shock: commonly 150–200 J biphasic for the first shock, then escalate according to defibrillator guidance/local policy.
• Immediately resume CPR for 2 minutes after the shock.
• Do not check rhythm or pulse immediately after the shock unless the patient shows signs of life.
• After 2 minutes, pause briefly for rhythm check.
• If VF/pVT persists, give a second shock and resume CPR for 2 minutes.
• If VF/pVT persists at the next check, give a third shock and resume CPR immediately.
• After the third shock, give:
  • Adrenaline 1 mg IV/IO
  • Amiodarone 300 mg IV/IO
• Continue cycles of 2 minutes CPR → rhythm check → shock if indicated.
• Repeat adrenaline 1 mg IV/IO every 3–5 minutes, usually on alternate cycles.
• If VF/pVT persists after the fifth shock, give amiodarone 150 mg IV/IO.
• If ROSC occurs, start post-resuscitation care.

🧊 Safe Defibrillation

• Ensure oxygen is not flowing directly across the chest during shock delivery.
• Announce clearly: “Stand clear”.
• Visually check that nobody is touching the patient, bed or trolley.
• Deliver the shock. Restart CPR immediately after the shock.

🚫 Non-Shockable Arrest: PEA / Asystole

🚫 In PEA and asystole, defibrillation is not indicated. Survival depends on high-quality CPR, early adrenaline, and finding a reversible cause.

• Start CPR immediately: 30 compressions : 2 breaths until an advanced airway is in place.
• Attach monitor/defibrillator and confirm rhythm.
• Check for signs of life and pulse only if rhythm appears compatible with output.
• Give adrenaline 1 mg IV/IO as soon as vascular access is obtained.
• Continue CPR for 2 minutes. Recheck rhythm after 2 minutes.
• If still PEA/asystole, continue CPR and repeat adrenaline 1 mg every 3–5 minutes.
• If VF/pulseless VT appears, change immediately to the shockable rhythm algorithm.
• If ROSC occurs, start post-resuscitation care.

🫀 PEA: Important Point

• PEA means organised electrical activity without a palpable pulse or effective cardiac output.
• Some patients have mechanical activity detectable on ultrasound but no effective circulation.
• Common reversible causes include hypovolaemia, hypoxia, tension pneumothorax, tamponade, massive PE, toxins and severe electrolyte disturbance.
• Bedside ultrasound may help identify reversible causes, but should not cause prolonged pauses in CPR.

📉 Asystole: Important Point

• Check the ECG carefully: confirm leads are attached, gain is appropriate and rhythm is not fine VF.
• True asystole is a non-shockable rhythm.
• Do not attempt defibrillation for true asystole.
• If P waves are present with no QRS complexes, consider ventricular standstill; pacing may be considered with expert help.
• There is no role for pacing in true asystole.

🔁 Reversible Causes: 4 Hs and 4 Ts

💊 ALS Drugs — Adult Cardiac Arrest

🫁 Airway and Ventilation During ALS

• Start with simple airway manoeuvres and bag-valve-mask ventilation.
• Use supraglottic airway or tracheal intubation only if trained and it does not interrupt compressions.
• Confirm tracheal tube placement with waveform capnography.
• Once advanced airway is in place, give continuous chest compressions with ventilation about 10 breaths/min.
• Avoid excessive ventilation because it reduces venous return and cardiac output during CPR.

🫀 Post-Resuscitation Care After ROSC

• Use ABCDE reassessment.
• Maintain oxygenation and ventilation; avoid severe hypoxia and avoid unnecessary hyperoxia.
• Obtain 12-lead ECG and consider urgent coronary reperfusion if STEMI or high suspicion of coronary occlusion.
• Treat hypotension with fluids, vasopressors/inotropes and senior/ICU support.
• Check glucose, temperature, electrolytes and arterial/venous blood gas.
• Identify and treat the cause of arrest.
• Admit to an appropriate monitored setting, usually ICU or coronary care depending on cause.

🦠 Infection / Aerosol Precautions

• Use appropriate PPE according to local infection-control policy.
• Do not use outdated COVID-specific algorithms as the default ALS pathway.
• If high-risk respiratory infection is suspected, prioritise staff safety while minimising delay to CPR and defibrillation.

📸 Resuscitation Algorithms / Images

Replace older COVID-specific images with the current local or Resuscitation Council UK adult ALS algorithm where possible.

💡 Clinical Pearls

• Shockable arrest is primarily a defibrillation problem; do not delay shocks.
• Non-shockable arrest is primarily a reversible-cause problem; give early adrenaline and search actively.
• After any shock, restart CPR immediately without checking pulse or rhythm.
• Capnography helps confirm airway placement, monitor CPR quality and identify possible ROSC.
• Good ALS is team-based: leadership, closed-loop communication and anticipation prevent pauses.

📚 References

• Resuscitation Council UK: Adult Advanced Life Support Guidelines 2025
• Resuscitation Council UK: Adult ALS Algorithm 2025
• NICE CKS: Cardiac arrest — out-of-hospital care, advanced life support adult

Resuscitation - Advanced Life Support