Cardiac Arrest Response and ACLS Protocols
Code Blue Activation and Response
Recognition of Cardiac Arrest
- Unresponsive - No response to verbal or tactile stimulation
- No normal breathing - Absent or agonal gasps only
- No pulse - Check carotid pulse for no more than 10 seconds
If any doubt exists, begin CPR immediately.
Immediate Actions (First Responder)
- Call for help - Activate Code Blue
- Begin chest compressions immediately
- Send someone to retrieve AED/defibrillator
- Begin BLS until code team arrives
Code Team Roles
| Role | Responsibilities |
|---|---|
| Team Leader | Directs resuscitation, makes treatment decisions |
| Airway Manager | Bag-mask ventilation, advanced airway, capnography |
| Compressor | High-quality chest compressions, rotate every 2 minutes |
| Defibrillator | Applies pads, rhythm analysis, defibrillation |
| IV/IO/Medications | Vascular access, medication administration |
| Recorder | Documents events, times, medications |
High-Quality CPR Standards
Chest Compression Requirements
| Parameter | Requirement |
|---|---|
| Rate | 100-120 compressions per minute |
| Depth | At least 2 inches (5 cm), max 2.4 inches |
| Recoil | Allow complete chest recoil between compressions |
| Interruptions | Minimize - CCF goal 80% or higher |
| Hand position | Lower half of sternum |
| Rotation | Every 2 minutes or sooner if fatigue |
Ventilation During CPR
- Without advanced airway: 30:2 compression-to-ventilation ratio
- With advanced airway: Continuous compressions, 1 breath every 6 seconds
- Avoid hyperventilation
- Capnography target: ETCO2 10 mmHg or higher
Cardiac Arrest Algorithms
Shockable Rhythms: VF/Pulseless VT
- Identify VF/pVT - Immediate defibrillation
- Biphasic: 120-200J or maximum if unknown
- Monophasic: 360J
- Resume CPR immediately for 2 minutes
- Rhythm check - If still VF/pVT:
- Defibrillate
- Resume CPR immediately
- Establish IV/IO access
- Epinephrine 1mg IV/IO every 3-5 minutes
- After 2nd shock if VF/pVT continues:
- Defibrillate
- Resume CPR immediately
- Amiodarone 300mg IV/IO bolus (may repeat 150mg)
- OR Lidocaine 1-1.5 mg/kg IV/IO
Non-Shockable Rhythms: Asystole/PEA
- Begin CPR immediately
- Epinephrine 1mg IV/IO as soon as possible
- Continue CPR for 2 minutes
- Rhythm check after 2 minutes
- Search for reversible causes (Hs and Ts)
Reversible Causes - Hs and Ts
| Hs | Ts |
|---|---|
| Hypovolemia - Fluid resuscitation | Tension pneumothorax - Needle decompression |
| Hypoxia - Oxygenation, airway | Tamponade - Pericardiocentesis |
| Hydrogen ion (acidosis) - Consider bicarb | Toxins - Specific antidotes |
| Hypo/Hyperkalemia - Check K+, treat | Thrombosis (pulmonary) - Consider fibrinolytics |
| Hypothermia - Warm aggressively | Thrombosis (coronary) - Consider PCI |
Post-Cardiac Arrest Care
Immediate Post-ROSC Management
Airway and Breathing
- Secure airway if not already done
- Verify tube placement with capnography
- Titrate FiO2 to SpO2 94-98% (avoid hyperoxia)
- Target ETCO2 35-45 mmHg
Circulation
- Continuous cardiac monitoring - 12-lead ECG STAT
- Target MAP 65 mmHg or higher (SBP 90 or higher)
- Vasopressor support: Norepinephrine first line
- Assess for STEMI - Emergent cardiac cath if indicated
Targeted Temperature Management (TTM)
- Indication: Comatose patients after ROSC
- Target: 32-36 degrees C for at least 24 hours
- Methods: Cooling blankets, cold IV fluids, intravascular devices
- Avoid fever for at least 72 hours
Post-Arrest Monitoring
| Parameter | Target |
|---|---|
| Blood pressure | MAP 65 or higher, SBP 90 or higher |
| Oxygen saturation | 94-98% |
| ETCO2 | 35-45 mmHg |
| Temperature | 32-36 degrees C (TTM) |
| Glucose | 144-180 mg/dL |
Pediatric Cardiac Arrest
PALS Algorithm
- Defibrillation: 2 J/kg then 4 J/kg then 4 J/kg or higher (max 10 J/kg)
- Epinephrine: 0.01 mg/kg IV/IO every 3-5 minutes
- Amiodarone: 5 mg/kg IV/IO bolus; may repeat twice
Pediatric Compression Depth
| Age | Compression Depth | Technique |
|---|---|---|
| Infant | 1.5 inches (4 cm) | 2 thumbs encircling or 2 fingers |
| Child (1-puberty) | 2 inches (5 cm) | 1 or 2 hands |
| Adolescent | 2-2.4 inches | 2 hands |