Clinical Presentation

• Unresponsive state
• No respiration, pulse, or blood pressure (BP)
  1. Establish unresponsiveness with no respiration or pulse. Call for help.
  2. Begin CPR, provide oxygen, and attach AED or monitor-defibrillator when available without interrupting CPR.
  3. When device is attached, stop CPR and assess rhythm. If shock is advised when using an AED, defibrillatefollowing the AED voice/visual prompts. If using a manual monitor-defibrillator and the rhythm is VF or pulseless VT, defibrillate at 120–200 J if using a biphasic defibrillator following manufacturer’s device-specific energy levels if known, or 200 J if unknown, or defibrillate at 360 J if using a monophasic defibrillator.
  4. Immediately resume CPR, beginning with compressions. Provide five cycles (2 min) of uninterrupted CPR. During CPR, establish IV or intraosseous (IV/IO) access. Prepare vasopressor dose (epinephrine or vasopressin).
  5. Assess rhythm. If the rhythm is shockable, follow AED voice/visual prompts or defibrillate at same or higher energy for biphasic manual defibrillator or at 360 J for a monophasic manual defibrillator.
  6. Immediately resume CPR beginning with compressions and using five cycles of 30 compressions and 2 breaths.
  7. Consider insertion of an advanced airway (ET tube intubation or supraglottic advanced airway) if basic airway management is inadequate. Once an advanced airway is in place, compressions should be uninterrupted at a rate of at least 100–120/min, and ventilations should be 10 breaths/min (1 breath every 6 sec). Use waveform capnography or capnometry to confirm and monitor ET tube placement.
  8. Administer epinephrine 1 mg (10 mL of 1:10,000) by the IV/IO method; follow with 20-mL IV flush. Repeat every 3–5 min. If no IV/IO access is available, give 2.0–2.5 mg (1:1000) epinephrine diluted in 5–10 mL normal saline or sterile water and administer by endotracheal (ET) tube every 3–5 min until IV/IO access is available.
  9. Continue CPR; check the rhythm every 2 min.
  10. If the rhythm is still shockable, defibrillate as in step 5.
  11. Immediately resume CPR; check the rhythm every 2 minutes.

  Consider antiarrhythmics for shock-refractory VF or pulseless VT:

12. Administer either amiodarone 300 mg IV/IO or lidocaine 1.0–1.5 mg/kg IV/IO. Because lidocaine is equivalent to amiodarone, as an antiarrhythmic, it is useful if the patient is allergic to amiodarone or if amiodarone is unavailable.
13. Repeat antiarrhythmic therapy for shock-refractory VF or VT: amiodarone 150 mg IV/IO in 3–5 min (use only one time); or lidocaine 0.5–0.75 mg/kg IV/IO. Repeat lidocaine every 5–10 min, maximum dose 3 mg/kg.
14. Consider magnesium sulfate 1–2 g (2–4 mL of a 50% solution) diluted in 10 mL of D5W IV/IO, given over 1–2 min for cardiac arrest caused by hypomagnesemia or torsade de pointes.

Clinical Tip: Do not delay defibrillation for a witnessed arrest. For an unwitnessed arrest with a down time greater than 4–5 min, perform 2 min of CPR before defibrillation.

Clinical Tip: Airway must be secured and placement verified with observation of chest rise and auscultation of breath sounds plus a confirmatory device (exhaled CO₂ detector). Monitor tube for displacement during transport or whenever patient is moved.