← PROTOCOLS
💔 Cardiac Arrest / CPR
Resuscitation • AED • ROSC Management
🔴 COMPRESSIONS FIRST
COMPRESSIONS ARE THE MOST IMPORTANT INTERVENTION
Push hard, push fast, minimize interruptions
100–120 Compressions / min
≥2″ Depth (not >2.4″)
<10 sec Max interruption
30:2 Ratio (no adv airway)
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2
Recognition & Initiation
  • Unresponsive? — No response to voice or sternal rub
  • No normal breathing? — Gasping = agonal breathing; treat as arrest — START CPR
  • No pulse >10 seconds? — Carotid pulse check; if uncertain, begin CPR
  • ⚠ Do not delay CPR to obtain history or full assessment
  • Note time CPR initiated — document witnessed vs. unwitnessed arrest
  • Activate dispatch notification; confirm ALS en route
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3
💪 High-Quality CPR
  • Rate: 100–120 compressions/min (use metronome if available)
  • Depth: ≥2 inches (5 cm) — do not exceed 2.4 inches (6 cm)
  • Full recoil: Allow complete chest recoil between compressions; do not lean
  • Minimize interruptions: Any pause must be <10 seconds
  • Ventilation: 1 breath every 6 sec with advanced airway — do NOT hyperventilate
  • Rotate compressors: Switch every 2 minutes or at each rhythm check to prevent fatigue
  • Ratio: 30:2 compressions to ventilations without advanced airway
  • ⚠ Avoid excessive ventilation — increases intrathoracic pressure, worsens survival
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4
⚡ AED — Defibrillation
  • Power on the AED immediately — follow audio/visual prompts
  • Pad placement: Right subclavicular (below collarbone, right sternal border) + Left lateral (mid-axillary line, 4th–5th intercostal space)
  • Dry chest, remove medication patches, use anterior-posterior if necessary
  • Analyze rhythm: Stop CPR, ensure no one is touching patient — "I'm clear, you're clear, everybody clear"
  • Shock if advised: Deliver shock, then immediately resume CPR — do NOT check pulse
  • Continue 2-minute CPR cycles between AED rhythm checks
  • ⚠ Every 1 minute without defibrillation in VF = ~10% decrease in survival
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5
Airway Management
  • BLS Head-tilt chin-lift (jaw thrust if trauma suspected)
  • BLS OPA sizing: Corner of mouth to earlobe; insert inverted and rotate 180°
  • BLS NPA sizing: Tip of nose to earlobe; contraindicated in suspected basilar skull fracture
  • BLS BVM: Two-person technique preferred — one holds mask seal (C-E clamp), one squeezes bag; deliver 1 breath every 6 sec
  • ALS Advanced airway (supraglottic or ETT): confirm placement, secure device, 10 breaths/min
  • ⚠ Visible chest rise = adequate ventilation; do not squeeze too hard or fast
  • ⚠ Hyperventilation worsens cardiac arrest outcomes — 1 breath/6 seconds maximum
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🧠 Step 6 — Reversible Causes: H’s & T’s

🧭 Select a potential reversible cause to see field management
H’s — Select to review
T’s — Select to review
Tap a cause above to see field assessment & management
7
ALS Interventions ALS
  • Epinephrine 1mg IV/IO q3–5 min:
    • Non-shockable (PEA/Asystole): Give as early as possible
    • Shockable (VF/pVT): Give after 3rd shock
  • Amiodarone: 300mg IV/IO (1st dose) for refractory VF/pVT; 150mg IV/IO (2nd dose)
  • IO access: If IV access fails after 2 attempts or >90 sec, establish IO (tibia, humerus)
  • Vasopressin 40 units IV/IO: May replace first or second dose of epinephrine (per protocol)
  • Sodium bicarbonate: Per protocol — tricyclic OD, hyperkalemia, prolonged arrest
  • Calcium chloride: Per protocol — hyperkalemia, calcium channel blocker OD
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Signs of ROSC?
Pulse, BP, purposeful movement, spontaneous breathing
YES — ROSC
Post-resuscitation care below ↓
NO — Continue
Continue CPR cycles; re-analyze H's & T's; consider termination criteria
8
ROSC Management — Post-Resuscitation Care
  • Signs of ROSC: Palpable pulse, rise in end-tidal CO2, purposeful movement, spontaneous breathing, return of BP
  • Position: 30° head of bed elevation (semi-Fowler's); recovery position if no spinal concern and unconscious
  • Oxygen: Titrate SpO2 94–98% — avoid hyperoxia (hyperoxia worsens neurological outcomes post-ROSC)
  • Ventilation: Target ETCO2 35–45 mmHg; avoid hypocapnia (ALS)
  • Blood glucose: Check BGL — treat hypoglycemia; avoid hyperglycemia
  • Temperature: Avoid hyperthermia; target normothermia (therapeutic hypothermia/TTM per ALS/ED)
  • 12-Lead ECG: Obtain as soon as possible — identify STEMI for cath lab activation
  • Hemodynamics: Target systolic BP >90 mmHg (ALS fluid/vasopressor management)
  • Transport: Notify receiving facility early — resuscitation hospital with cath lab preferred
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9
Termination of Resuscitation
  • ⚠ Always follow local protocol — medical director authorization required in most jurisdictions
  • General considerations for termination:
    • Unwitnessed arrest with prolonged downtime
    • Non-shockable rhythm throughout
    • No ROSC after adequate resuscitation effort
    • No signs of life at any time during resuscitation
    • Obvious signs of death (rigor mortis, dependent lividity, decapitation, incineration)
  • Contact ALS unit or medical director via radio/phone before terminating
  • Document all times, interventions, rhythm strips, and personnel present
  • Family notification: compassionate, clear, avoid jargon; offer chaplain/support resources
  • Scene preservation: if cardiac arrest has any suspicious circumstances, do not disturb scene

⚠️ Special Circumstances

Situation Key Considerations
❄️ Hypothermia "Not dead until warm and dead" — aggressive resuscitation and transport to hospital for active rewarming. Rewarm core before terminating. Cold CPR is effective.
🌊 Drowning Extended resuscitation — oxygenation is the priority. 5 initial rescue breaths before compressions. Hypothermia common; see above. Good neurological outcomes reported after prolonged submersion in cold water.
🫃 Pregnancy Left lateral uterine displacement (manual) to relieve aortocaval compression. If >20 weeks gestation, consider perimortem cesarean by hospital within 5 minutes of arrest. Call OB/GYN early.
👶 Pediatric Compression depth: 1.5″ infant, 2″ child. Ratio: 30:2 single rescuer / 15:2 two rescuers. AED: use pediatric pads/attenuator for <8 years or <25 kg. Shockable rhythms less common — focus on airway and oxygenation.

🚨 ALS Intercept — Always Request

🔴 ALS Required for Cardiac Arrest
  • All confirmed cardiac arrests — ALS should be en route on initial dispatch
  • ROSC achieved — advanced airway, 12-lead, vasopressors, TTM protocols
  • Suspected reversible cause requiring ALS intervention (tension PTX, tamponade)
  • Refractory VF/pVT requiring antiarrhythmics
  • Pediatric arrest — additional expertise and medications
  • Medical direction needed for termination of resuscitation