Evidence-Based Protocol

CPR & Code
Management

From Basic Life Support to Advanced Cardiac Life Support β€” A Complete Guide

AHA 2020 Guidelines MBBS / MD Level BLS + ACLS
100–120
Compressions / min
30 : 2
Compression : Ventilation
β‰₯ 5 cm
Compression Depth (Adult)

Chain of Survival β€” AHA 2020

πŸ“ž
1. Recognition &
Activation
🫁
2. Early
CPR
⚑
3. Rapid
Defibrillation
πŸ₯
4. Advanced
Life Support
🩺
5. Post-Cardiac
Arrest Care

Key Metrics at a Glance

Parameter Adult Child (1–Puberty) Infant (<1 yr)
Compression Depth β‰₯ 5 cm (2 in) β‰₯ 5 cm (β…“ AP) 4 cm (1.5 in / β…“ AP)
Rate 100–120/min 100–120/min 100–120/min
C:V Ratio (1 rescuer) 30:2 30:2 30:2
C:V Ratio (2 rescuer) 30:2 15:2 15:2
Hand Position 2 hands, lower Β½ sternum 1–2 hands, lower Β½ sternum 2 fingers / 2 thumb-encircling
AED Shock (Biphasic) 120–200 J 2 J/kg β†’ 4 J/kg 2 J/kg β†’ 4 J/kg

Basic Life Support β€” C-A-B Approach

1

Scene Safety & Response Check

  • β€’ Ensure scene is safe for rescuer and victim
  • β€’ Tap & Shout: "Are you okay?" β€” tap shoulders firmly
  • β€’ Check for normal breathing (gasping is NOT normal breathing)
  • β€’ If unresponsive + no normal breathing β†’ Activate EMS + Get AED
  • β€’ Lone rescuer: use phone on speaker, start CPR immediately
2

Pulse Check (Healthcare Provider)

  • β€’ Carotid pulse for adults/children; Brachial pulse for infants
  • β€’ Check for no more than 10 seconds
  • β€’ If no definite pulse within 10 sec β†’ Begin CPR
  • β€’ If pulse present but no breathing β†’ Rescue breathing (1 breath every 6 sec for adults; every 2–3 sec for infants/children)
C

Circulation β€” Chest Compressions

  • β€’ Heel of hand on lower half of sternum
  • β€’ Rate: 100–120/min | Depth: β‰₯ 5 cm but ≀ 6 cm
  • β€’ Allow complete chest recoil β€” don't lean on chest
  • β€’ Minimize interruptions: < 10 seconds pauses
  • β€’ Rotate compressors every 2 minutes (5 cycles of 30:2)
  • β€’ Hard & Fast, Push & Release β€” "Stayin' Alive" tempo
A

Airway β€” Open the Airway

  • β€’ Head-tilt, Chin-lift maneuver (primary technique)
  • β€’ Jaw-thrust if suspected cervical spine injury
  • β€’ Suction if visible obstruction; consider oropharyngeal/nasopharyngeal airway
B

Breathing β€” Ventilation

  • β€’ 30:2 ratio (compressions:breaths) without advanced airway
  • β€’ Each breath over 1 second, visible chest rise
  • β€’ Avoid excessive ventilation β€” causes gastric insufflation, ↑ intrathoracic pressure, ↓ venous return
  • β€’ With advanced airway: Continuous compressions + 1 breath every 6 sec (10 breaths/min)
  • β€’ BVM with Oβ‚‚ reservoir at 15 L/min β†’ delivers ~100% FiOβ‚‚
D

Defibrillation β€” AED Use

  • β€’ Use AED as soon as available
  • β€’ Power ON β†’ Attach pads β†’ Analyze β†’ Shock if advised
  • β€’ Resume CPR immediately after shock β€” do NOT recheck rhythm
  • β€’ Reanalyze every 2 minutes
  • β€’ Anterior-lateral pad placement (right infraclavicular + left axillary)
  • β€’ Special: Water β†’ dry chest; Patches β†’ remove; Pacemaker β†’ place pad 1 inch away

High-Quality CPR Checklist

βœ… Rate 100–120/min
βœ… Depth β‰₯ 5 cm (adult)
βœ… Full chest recoil
βœ… Minimize interruptions (<10 sec)
βœ… Avoid excessive ventilation
βœ… Rotate compressors q 2 min
βœ… Chest compression fraction > 60%
βœ… EtCOβ‚‚ target β‰₯ 10 mmHg (if monitored)

ACLS β€” Advanced Cardiac Life Support

Code Team β€” Role Assignment

🎯 Team Leader
Directs all actions, assigns roles, makes rhythm/drug decisions, maintains situational awareness
πŸ’ͺ Compressor
Delivers high-quality compressions, rotates every 2 min, calls out depth/rate
🫁 Airway Manager
BVM ventilation β†’ advanced airway (ETT/SGA), monitors EtCOβ‚‚, ensures Oβ‚‚ flow
πŸ’‰ IV/IO & Medications
Establishes IV/IO access, prepares & administers drugs, flushes with 20 mL NS + elevates extremity
⚑ Defibrillator/Monitor
Operates defibrillator, monitors rhythm, charges during compressions, announces shock
πŸ“‹ Recorder/Timer
Documents events, timestamps drugs & shocks, calls 2-min intervals, tracks epinephrine q3–5 min

Algorithm Flow:

  1. CPR 2 min β†’ Rhythm check β†’ VF/pVT identified
  2. Shock #1: Biphasic 120–200 J (or manufacturer dose) / Mono 360 J
  3. CPR 2 min immediately β†’ IV/IO access during compressions
  4. Rhythm check β†’ Still VF/pVT β†’ Shock #2
  5. CPR 2 min + Epinephrine 1 mg IV/IO (then q 3–5 min)
  6. Rhythm check β†’ Still VF/pVT β†’ Shock #3
  7. CPR 2 min + Amiodarone 300 mg IV/IO (1st dose)
  8. Continue cycle: CPR β†’ Rhythm check β†’ Shock β†’ Drug
  9. Amiodarone 150 mg (2nd dose) can be given
  10. Consider Lidocaine if Amiodarone unavailable: 1–1.5 mg/kg β†’ 0.5–0.75 mg/kg

Key point: Epinephrine starts AFTER 2nd shock. Amiodarone starts AFTER 3rd shock. Every shock is followed by IMMEDIATE CPR β€” never delay compressions to recheck pulse.

Algorithm Flow:

  1. CPR 2 min β†’ Rhythm check β†’ Asystole/PEA identified
  2. Epinephrine 1 mg IV/IO ASAP (then q 3–5 min)
  3. CPR 2 min β†’ Rhythm check
  4. If rhythm changes to VF/pVT β†’ Switch to shockable algorithm
  5. If still asystole/PEA β†’ Continue CPR + Epi q 3–5 min
  6. Aggressively search for H's & T's

Key difference: Epinephrine given ASAP (not after 2nd shock). No antiarrhythmics. No shocks. Treat the CAUSE β€” PEA often has a reversible etiology.

Confirm Asystole: Check leads, gain/amplitude, check in 2 leads. "Asystole protocol" β€” confirm it's not fine VF.

EtCOβ‚‚ (Capnography)

  • β€’ Target: β‰₯ 10 mmHg during CPR
  • β€’ If <10 β†’ improve compression quality
  • β€’ Sudden rise to β‰₯ 40 mmHg β†’ suggests ROSC
  • β€’ Best physiologic indicator of CPR quality
  • β€’ Also confirms ETT placement

Arterial Line (if placed)

  • β€’ Diastolic pressure β‰₯ 20 mmHg target
  • β€’ Correlates with coronary perfusion pressure
  • β€’ If <20 β†’ optimize compressions
  • β€’ Consider vasopressors

Cardiac Arrest Rhythms

SHOCKABLE

Ventricular Fibrillation (VF)

  • β€’ Chaotic, irregular electrical activity β€” no organized QRS
  • β€’ No cardiac output β€” immediate defibrillation needed
  • β€’ Most common initial rhythm in witnessed adult cardiac arrest
  • β€’ Best prognosis of all arrest rhythms when treated early
SHOCKABLE

Pulseless V-Tach (pVT)

  • β€’ Wide, regular QRS complexes β€” rate usually >150 bpm
  • β€’ Monomorphic or polymorphic morphology
  • β€’ No palpable pulse β†’ treat as cardiac arrest
  • β€’ Polymorphic VT (Torsades) β†’ Magnesium 1–2 g IV
NON-SHOCKABLE

Asystole

  • β€’ Flatline β€” no ventricular electrical activity
  • β€’ Confirm in 2 leads; check connections, gain
  • β€’ Do NOT defibrillate β€” no rhythm to reset
  • β€’ Worst prognosis β€” focus on reversible causes (H's & T's)
NON-SHOCKABLE

PEA (Pulseless Electrical Activity)

  • β€’ Organized electrical activity but no palpable pulse
  • β€’ Can look like any rhythm β€” sinus, bradycardia, etc.
  • β€’ Most commonly has a reversible cause
  • β€’ Aggressively treat H's & T's β€” often the best chance at ROSC

Code Medications

Epinephrine (Adrenaline)

First-Line Vasopressor
πŸ’‰

Dose & Route

  • β€’ 1 mg IV/IO every 3–5 minutes
  • β€’ Follow with 20 mL NS flush
  • β€’ Elevate extremity for 10–20 sec

Timing

  • β€’ VF/pVT: After 2nd shock
  • β€’ Asystole/PEA: As soon as possible
  • β€’ Ξ±-1 effects β†’ ↑ coronary perfusion pressure

Amiodarone

Antiarrhythmic β€” Class III
⚑

Dose

  • β€’ 1st dose: 300 mg IV/IO bolus
  • β€’ 2nd dose: 150 mg IV/IO
  • β€’ Pediatric: 5 mg/kg IV/IO (max 300 mg)

Indication

  • β€’ Refractory VF/pVT β€” after 3rd shock
  • β€’ K⁺/Na⁺/Ca²⁺ channel + Ξ²-blocker activity
  • β€’ Prolongs action potential duration

Lidocaine

Antiarrhythmic β€” Class Ib
πŸ’Š
  • β€’ Alternative to amiodarone if unavailable
  • β€’ 1st dose: 1–1.5 mg/kg IV/IO
  • β€’ 2nd dose: 0.5–0.75 mg/kg (every 5–10 min; max 3 mg/kg)

Other Code Medications

Magnesium Sulfate

1–2 g IV/IO diluted in 10 mL D5W

Indication: Torsades de Pointes

Sodium Bicarbonate

1 mEq/kg IV

Indication: Hyperkalemia, TCA overdose, metabolic acidosis

Calcium Chloride 10%

20 mg/kg IV (max 2 g) β€” via central line preferred

Indication: Hyperkalemia, hypocalcemia, Ca²⁺ blocker OD

Atropine

1 mg IV q 3–5 min (max 3 mg)

Indication: Symptomatic bradycardia (NOT routine in arrest)

Vascular Access Priority

1st: IV (peripheral β€” antecubital preferred) β†’ 2nd: IO (proximal tibia, humeral head) β†’ 3rd: Central line (if skilled)

All drugs: Follow with 20 mL NS bolus + elevate extremity. IO doses = IV doses.

Post-ROSC Management

ROSC = Return of Spontaneous Circulation

Signs: palpable pulse, sudden sustained ↑ EtCOβ‚‚ (typically β‰₯40 mmHg), arterial pressure wave, spontaneous breathing/movement.

🫁 Ventilation & Oxygenation

β€’ Titrate FiOβ‚‚ to SpOβ‚‚ 92–98% β€” avoid hyperoxia (causes oxidative injury)

β€’ Ventilation rate: 10 breaths/min

β€’ Target EtCOβ‚‚ 35–45 mmHg (normocapnia) β€” or PaCOβ‚‚ 35–45

β€’ Avoid hypocapnia (↓ cerebral blood flow) and hypercapnia

β€’ Secure advanced airway if not already placed; confirm with waveform capnography

❀️ Hemodynamic Optimization

β€’ Target SBP β‰₯ 90 mmHg or MAP β‰₯ 65 mmHg

β€’ IV fluid bolus (1–2 L NS) for hypotension

β€’ Vasopressors if needed: Norepinephrine (0.1–0.5 mcg/kg/min) or Epinephrine infusion (0.1–0.5 mcg/kg/min)

β€’ 12-Lead ECG β€” if STEMI β†’ emergent PCI (even if comatose)

β€’ Dopamine: 5–20 mcg/kg/min (alternative vasopressor)

🧠 Targeted Temperature Management (TTM)

β€’ For comatose patients (no meaningful response to verbal commands) after ROSC

β€’ Target: 32–36Β°C for β‰₯ 24 hours (AHA 2020: select and maintain constant temp)

β€’ Methods: IV cold saline, surface cooling devices, endovascular catheters

β€’ Actively prevent fever (β‰₯37.7Β°C) for at least 72 hours

β€’ Rewarm slowly: 0.25–0.5Β°C/hour

β€’ Prevents secondary neuronal injury from reperfusion

πŸ”¬ Investigations Post-ROSC

Immediate

  • β€’ 12-Lead ECG
  • β€’ ABG (pH, lactate, electrolytes)
  • β€’ CBC, BMP, Troponin
  • β€’ Coagulation profile
  • β€’ Chest X-ray
  • β€’ Glucose β€” treat hypoglycemia

Consider

  • β€’ CT Head (if no clear cardiac cause)
  • β€’ CT Pulmonary Angiography (suspected PE)
  • β€’ Echocardiography
  • β€’ Coronary angiography (STEMI/high suspicion ACS)
  • β€’ EEG monitoring (seizure detection)
  • β€’ Toxicology screen

πŸ§ͺ Neuroprognostication

β€’ Wait β‰₯ 72 hours after ROSC (or after rewarming from TTM) before prognostication

β€’ Multimodal approach: clinical exam (pupillary/corneal reflexes, motor response), EEG, SSEP, MRI, NSE biomarkers

β€’ No single test should be used alone to predict poor outcome

Reversible Causes β€” The H's & T's

Systematically consider these during every cardiac arrest β€” especially PEA and asystole. Identifying and treating the cause is often the only path to ROSC.

H The H's

Hypovolemia

Clues: Hx of bleeding/trauma, flat neck veins, narrow pulse pressure on monitor

Tx: IV crystalloid bolus, blood products (PRBCs), stop hemorrhage source, massive transfusion protocol

Hypoxia

Clues: Cyanosis, airway obstruction, Hx of respiratory disease

Tx: Effective ventilation with 100% Oβ‚‚, confirm advanced airway placement, waveform capnography

Hydrogen Ion (Acidosis)

Clues: DKA, renal failure, prolonged arrest, sepsis, diarrhea

Tx: Sodium Bicarbonate 1 mEq/kg IV; ventilation (respiratory compensation); treat underlying cause

Hyper/Hypokalemia

Clues: Renal failure, dialysis patient, medications (ACEi, K-sparing diuretics), ECG changes

Tx Hyperkalemia: Calcium Chloride/Gluconate, NaHCO₃, Insulin + Glucose, Kayexalate, emergent dialysis

Tx Hypokalemia: IV KCl replacement (10–20 mEq/hr peripherally; faster via central line)

Hypothermia

Clues: Exposure history, cold skin, core temp <35Β°C

Tx: Active rewarming (warm IV fluids 40Β°C, warm blankets, body cavity lavage in severe cases). May need prolonged resuscitation β€” "not dead until warm and dead"

T The T's

Tension Pneumothorax

Clues: Unilateral absent breath sounds, tracheal deviation, distended neck veins, trauma/ventilated patient

Tx: Needle decompression (2nd ICS, midclavicular or 4th/5th ICS, anterior axillary) β†’ chest tube

Tamponade (Cardiac)

Clues: Beck's triad (muffled heart sounds, JVD, hypotension), PEA with narrow QRS, pericardial effusion on echo

Tx: Pericardiocentesis (needle or surgical) β†’ definitive surgical repair. Bedside echo is diagnostic gold standard

Toxins / Overdose

Clues: Pill bottles, medication Hx, toxidromes, young patient, unknown cause arrest

Tx: Specific antidotes β€” Narcan (opioids), NaHCO₃ (TCA/Na-channel blockers), Intralipid (local anesthetic toxicity), Flumazenil (benzos β€” use with caution), Digibind (digoxin). Prolonged CPR may be warranted

Thrombosis β€” Pulmonary (PE)

Clues: Recent surgery/immobilization, DVT Hx, RV dilation on echo, sudden PEA arrest

Tx: Systemic thrombolytics (tPA 50 mg IV bolus during CPR or alteplase); consider surgical/catheter-directed embolectomy. Continue CPR for 60–90 min after lytic administration

Thrombosis β€” Coronary (MI)

Clues: Hx of CAD/chest pain, STEMI on monitor, age/risk factors

Tx: Emergent coronary angiography + PCI (even during ongoing CPR in select cases β€” cath lab CPR). Consider fibrinolytics if PCI unavailable

πŸ’‘ Quick Memory Aid

5 H's:

Hypovolemia, Hypoxia, Hydrogen ion, Hyper/Hypokalemia, Hypothermia

5 T's:

Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary), Thrombosis (coronary)