Adult Cardiac Arrest Algorithm―2018 Update

This figure conveys the Adult Cardiac Arrest Algorithm, which was updated in 2015. It includes a flowchart on the left and a table of related information on the right. The flowchart consists of numerous numbered boxes and unnumbered hexagons linked together with arrows. At the top, box 1, which is blue, is labeled “Start CPR.” It contains two points of text:
  • Give oxygen.
  • Attach monitor or defibrillator.
A downward arrow leads to the first red hexagon that poses the question, “[Is the] rhythm shockable?” Possible responses are “Yes” and “No,” and each leads to a different pathway. In this description, we will first follow the “Yes” pathway to its end before looking at the “No” pathway. Following the “Yes” arrow to the left and down leads to box number 2, which is white. It is labeled “VF/pVT,” which stands for Ventricular Fibrillation and Pulseless Ventricular Tachycardia.” From here, an arrow points downward to item 3: a red lightning bolt icon labeled “Shock.” Continuing on, an arrow points down to box 4, which is blue, labeled “CPR 2 minutes.” Its corresponding text says “IV or I.O. access.” (“IV” is short for “Intravenous,” and “I.O.” stands for “intraosseous.” The next arrow leads to a second red hexagon that asks the same question as before: “[Is the] rhythm shockable?” From here, let’s continue to focus on the “Yes” pathway. It leads to item 5, another red lightning bolt labeled “Shock.” An arrow points down to box 6, which is blue and titled “CPR 2 minutes.” Its related text says:
  • Epinephrine every 3 to 5 minutes.
  • Consider advanced airway, capnography.
This leads to the third red hexagon with the question: “[Is the] rhythm shockable?” Continuing to look at the “Yes” pathway, an arrow leads to item 7, a red lightning bolt labeled “Shock.” Item 8 is a blue box titled “CPR 2 minutes.” Its text says:
  • Amiodarone or lidocane
  • Treat reversible causes.
This box has an arrow that circles back to the second red hexagon that asks, “[Is the] rhythm shockable?” At the second and third red hexagons in this pathway, if the answer to the question ““[Is the] rhythm shockable?” is “No, the flowchart points to box 12. This white box contains the text:
  • If no signs of return of spontaneous circulation, or ROSC, go to [box] 10 or 11.
  • If ROSC, go to Post–Cardiac Arrest Care.
As mentioned earlier, the flowchart splits at the first red hexagon into two pathways. If the answer to the initial question, “[Is the] rhythm shockable?” had been “No,” an arrow points down and to the right to box 9. This white box says, “Asystole or Pulseless electrical activity (P.E.A.). From box 9, an arrow leads downward to box 10. This blue box is titled CPR 2 minutes.” It contains the following text:
  • IV or I.O. access.
  • Epinephrine every 3 to 5 minutes.
  • Consider advanced airway, capnography.
An arrow points down to the second red hexagon in this pathway. It, too, asks, “[Is the] rhythm shockable?” If the answer is “No,” an arrow leads to box 11. This blue box is labeled “CPR 2 minutes” and contains the text, “Treat reversible causes.” From there, an arrow leads to the third red hexagon along this path. If the answer to the question, “[Is the] rhythm shockable?” is “No,” an arrow points to box 12. As mentioned earlier, it states:
  • If no signs of return of spontaneous circulation, or ROSC, go to [box] 10 or 11.
  • If ROSC, go to Post–Cardiac Arrest Care.
If, at the second or third hexagon in this pathway the answer to the question, “[Is the] rhythm shockable?” is “Yes,” arrows lead to a white box that says, “Go to [items] 5 or 7.” As mentioned earlier, they are represented by a red lightning bolt and contain the text “Shock.” The table on the right contains bulleted text related to six different topics. The first topic is “CPR Quality.” The corresponding text states:
  • Push hard (at least 2 inches or 5 centimeters) and fast (100 to 120 compressions per minute) and allow complete chest recoil.
  • Minimize interruptions in compressions.
  • Avoid excessive ventilation.
  • Rotate compressor every 2 minutes, or sooner if fatigued.
  • If no advanced airway, use a 30-to-2 compression-to-ventilation ratio.
  • Quantitative waveform capnography: If PETCO2 is less than 10 millimeters of mercury, attempt to improve CPR quality.
  • Intra-arterial pressure: If relaxation phase (diastolic) pressure is less than 20 millimeters of mercury, attempt to improve CPR quality.
The second topic is “Shock Energy for Defibrillation.” The related text says:
  • Biphasic: Manufacturer recommendation (for example, initial dose of 120 to 200 Joules); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered.
  • Monophasic: 360 Joules.
The third topic is “Drug Therapy.” The associated text states:
  • Epinephrine IV or I.O. dose: 1 milligram every 3 to 5 minutes.
  • Amiodarone IV or I.O. dose: First dose: 300 milligram bolus. Second dose: 150 milligrams.
  • Or Lidocaine IV or I.O. dose: First dose: 1 to 1.5 milligrams. Second dose: 0.5 to 0.75 milligrams.
The fourth topic is “Advanced Airway.” The corresponding text says:
  • Endotracheal intubation or supraglottic advanced airway.
  • Waveform capnography or capnometry to confirm and monitor E.T. tube placement.
  • Once advanced airway is in place, give 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions.
The fifth topic is “Return of Spontaneous Circulation, or ROSC.” The related text states:
  • Pulse and blood pressure.
  • Abrupt sustained increase in PETCO2 (typically greater than or equal to 40 millimeters of mercury).
  • Spontaneous arterial pressure waves with intra-arterial monitoring.
The final topic is “Reversible Causes.” The associated text says:
  • Hypovolemia.
  • Hypoxia.
  • Hydrogen ion (acidosis).
  • Hypo- or hyperkalemia.
  • Hypothermia.
  • Tension pneumothorax.
  • Tamponade, cardiac.
  • Toxins.
  • Thrombosis, pulmonary.
  • Thrombosis, coronary.
This figure is copyright 2015 by the American Heart Association.