Cardiopulmonary Resuscitation

See Also

Epidemiology

Pediatric Cardiac Arrest Incidence: 3.3 to 8 cases per 100,000 in U.S.
1. Out of hospital arrest ROSC: 23% (10% survival rate)
2. Best ROSC and survival rates are for teen Cardiac Arrests (infants have the lowest rates)
Neurologically Intact Survival after out-of-hospital Cardiac Arrest
1. Infant: 1 to 2%
2. Child: 4%
3. Teen: 11 to 16%
4. Adult: 2 to 10%
U.S. black and hispanic patients are significantly less likely to receive bystander CPR (home or public setting)
1. Garcia (2022) N Engl J Med 387(17):1569-78 +PMID: 36300973 [PubMed]

Precautions

Protocol

See Adult Resuscitation (ACLS
See Pediatric Resuscitation (PALS)
See Newborn Resuscitation
Typically ACLS, ATLS, PALS are taught in isolation (outside CALS Course)
1. ATLS is integrated with ACLS and PALS for the purposes of this reference

Management
Assess Responsiveness

Responsive
1. See Rapid ABC Assessment
Unresponsive
1. See Altered Level of Consciousness
2. Call for Help
  1. Call for Defibrillator if available
  2. Activate EMS after initial ABC assessment

Management
Emergency Airway

See Primary Survey Airway Evaluation
Position
1. Turn on back as unit
2. Support head and neck while positioning
3. Place on hard firm surface
Open airway
1. Jaw Thrust (if suspected neck injury)
2. Head Tilt-Chin Lift Maneuver
Trauma points (Primary Survey Airway Evaluation)
1. Is the patient speaking or vocalizing?
2. Observe for foreign bodies, dentures and facial deformities interfering with airway maintenance
3. Primary Survey Disability Evaluation (brief Neurologic Exam)
  1. Also described below as the D-part of the ABCDE Trauma algorithm
  2. Can be performed with airway (GCS, pupils and motor in all extremities)
  3. Critical to perform with airway if Rapid Sequence Intubation (RSI) or Conscious Sedation administered

Management
Emergency Breathing

See Primary Survey Breathing Evaluation
Breathing is assessed by medical providers concurrently with responsiveness
1. Look Listen and feel for breathing has been removed from the ACLS and PALS sequence
Rescue breaths are now started after one cycle of compressions (in Cardiac Arrest)
1. New sequence: Compressions, open airway, give breaths
Attempt 2 ventilations (each lasting 1 second) if not breathing
1. Observe chest rise
2. Allow deflation between breaths
3. Reposition if first breath does not go in
Airway Obstruction (if ventilations unsuccessful)
1. No blind finger sweeps at any age
2. Unconscious
  1. Deliver full CPR regardless of airway obstruction
3. Conscious
  1. Perform Heimlich Maneuver
    1. Infants: 5 chest thrusts and 5 back blows
    2. Children: 5 abdominal thrusts
    3. Adults: 6-10 abdominal thrusts
  2. Attempt ventilation
  3. Repeat cycle until obstruction cleared
Trauma points (Primary Survey Breathing Evaluation)
1. Palpate the chest for deformities, Flail Chest or open wounds
2. Breath sounds are most useful when absent
  1. Treat asymmetrically absent breath sounds as a Pneumothorax
  2. Presence of breath sounds does not exclude Pneumothorax

Management
Emergency Circulation

See Primary Survey Circulation Evaluation
Assess for Pulse (health care providers)
1. Brachial Pulse in infants
2. Carotid Pulse in children and adults
Pulse Present: Perform Rescue Breathing (reassess every 2 minutes)
1. Endotracheal Tube: 1 breath per 6-8 seconds for all ages (8 to 10 breaths per minute)
2. Adult: 10 breaths per minute (every 6 seconds) in BLS
  1. Replaces Adult: 12 breaths/min (every 5 sec)
3. Infant and Child breaths: 20-30 breaths/min (every 2-3 seconds) in BLS
  1. Replaces Child: 15 breaths per minute (every 4 seconds)
  2. Replaces Infant: 20 breaths per minute (every 3 seconds)
Pulse Absent: Chest Compressions
1. General
  1. Pulse check should be <10 seconds
    1. EtCO2 is a reliable marker for ROSC (if pulses are difficult to palpate)
    2. Bedside Ultrasound may prolong pulse checks (restart compressions on timer)
    3. Huis (2017) Resuscitation 119:95-98 PMID:28754527 [PubMed]
  2. Perform 5 cycles in 2 minutes
  3. Reassess pulse and rhythm every 2 minutes
  4. Focus on pressing hard and fast with minimal interruptions
  5. Connect Automatic External Defibrillator as soon as available
  6. Time interval for lone rescuer calling for help
    1. Sudden Collapse: Call immediately
      1. Minimizes time to AED application
    2. Asphyxial arrest: Perform CPR for 2 minutes
  7. Two rescuers switch places every 2 minutes
    1. Prevents rescuer Fatigue with Chest Compressions
    2. Repeat pulse and rhythm checks with the change
2. Infants (Under 1 year old)
  1. Place 2 fingers at just below mid-nipple line
    1. Alternatively, hands encircle chest and both thumbs compress chest
  2. Compress over 100 times per minute
    1. Depth: One third of chest depth (1.5 inches or 4 cm)
    2. Compression to ventilation ratio
      1. Infant <1 month old: 3:1
      2. One rescuer: 30:2
      3. Two health care providers: 15:2
3. Children (1-8 years old)
  1. One hand placed over Sternum at center of chest (superior to xiphoid)
  2. Compress over 100 times per minute
    1. Depth: One third of chest depth (2 inches or 5 cm)
    2. Compression to ventilation ratio
      1. One rescuer: 30:2
      2. Two health care providers: 15:2
4. Adults (over 8 years old)
  1. Two hands placed over Sternum at center of chest (superior to xiphoid)
  2. Compress 100 times per minute
    1. Depth: 2 inches or 5 cm
    2. Compression to ventilation ratio: 30:2 (one or two rescuers)
Trauma Points (Primary Survey Circulation Evaluation)
1. See Primary Survey Circulation Evaluation
2. Warm feet are a reassuring sign (cold feet might suggest shock state)
3. Palpate the Abdomen for distention or signs of injury (source of occult bleeding)
4. Compress the Pelvis by pushing both iliac crests together with force
  1. Assess for anterior or posterior Pelvis injury
  2. If the Pelvis moves inward on compression
    1. Hold this position and apply a Pelvic Binder for stabilization
    2. Do not repeat this exam in an unstable Pelvis

Management
Trauma Disability Points (Primary Survey Disability Evaluation)

May be performed simultaneously with the airway evaluation above
Glasgow Coma Scale
Pupil Reaction
Can patient move all extremities?
1. In Trauma, do not paralyze and intubate the patient prior to assessing for Spinal Cord Injury with paralysis

Management
Trauma Exposure Points (Primary Survey Exposure Evaluation)

All clothing should be removed to completely assess for injuries
Exposure Penetrating Trauma first
Mnemonic: Armpits, Back, Butt cheeks and Sac
1. Assess for easily missed sites of injury
Apply warm blankets

Management
Trauma - Additional Points

Fast and Glucose/Girl (F and G in the Trauma ABCDEFG)
1. Perform FAST Exam (Ultrasound)
2. Check Serum Glucose
3. Check serum or Urine Pregnancy Test
Spine Precautions
1. Backboard may be discontinued when Primary Survey completed
2. Even with Spinal Injury, Backboard risks are much greater than benefit and should be removed soon after arrival
Imaging
1. CT Head
  1. Indicated for signs of Head Injury (especially if anticoagulated, Intoxication)
  2. See Head Injury CT Indications in Adults
  3. See Head Injury CT Indications in Children (PECARN)
2. CT C-Spine
  1. Indicated for any ill patient who needs spine imaging (replaces Cross Table lateral XRay)
  2. See Cervical Spine Imaging in Acute Traumatic Injury (e.g. NEXUS Criteria)
3. Chest XRay for all Trauma patients
4. CT Abdomen and Pelvis
  1. May skip if benign Abdomen and Pelvis without pain, tenderness and if vitals signs stable

Management
Rhythm - Pulse Absent in adults and children (ACLS and PALS)

See Reversible Causes of Cardiopulmonary Arrest (5H5T)
Shockable Rhythm: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
1. Defibrillate every 2 minutes
  1. Adult: Biphasic dose varies by device (120-200 J); Monophasic dose 360 J
  2. Children: Start at 2-4 J/kg, then 4 J/kg
  3. Start charging the Defibrillator before CPR is paused (decreases hands-off time)
    1. See above for reference
2. CPR
  1. Performed continuously between shocks (minimal interruptions)
3. Alpha-adrenergic agent (choose one)
  1. Epinephrine
    1. Adult: 1 mg every 3-5 minutes
    2. Child: 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
  2. Vasopressin (not commonly used in community EDs and removed from 2015 ACLS guidelines)
    1. Adult: 40 units for 1 dose
4. Antiarrhythmic
  1. Amiodarone (preferred)
    1. Adult: 300 mg IV (may subsequently repeat once at dose 150 mg)
    2. Child: 5 mg/kg bolus (and may be repeated up to twice for refractory VF/VT)
  2. Lidocaine (alternative for adults, not recommended in children)
    1. Adult: 1-1.5 mg/kg IV (may subsequently repeat dose at 0.5 to 0.75 mg/kg)
    2. Prior to 2002 Alive Trial, Lidocaine had been the primary agent in VT/VF
      1. However, In 2023-2025 several studies have shown improved survival with Lidocaine
    3. Lidocaine is a cleaner drug, acting only at Sodium channels, with onset in seconds (duration <20 min)
      1. Contrast with Amiodarone which blocks multiple channels (Na+, K+, Ca++, beta) and delayed peak
    4. Lidocaine is preferred in certain scenarios
      1. Brugada Syndrome
      2. Torsades de Pointes (after Magnesium)
      3. Ischemia related Ventricular Tachycardia
    5. References
      1. Swaminathan and Hedayati (2026) Anti-Dysrhythmics in VT/VF Arrest, EM:Rap 4/6/2026
5. Magnesium (for Torsades de Pointes)
  1. Adult: 1-2 g IV
  2. Child: 25 to 50 mg/kg IV or IO
Non-shockable Rhythm: Asystole or Pulseless Electrical Activity (PEA)
1. Key management is to identify and treat Reversible Causes of Cardiopulmonary Arrest (5H5T)
2. Epinephrine
  1. Adult: 1 mg every 3-5 minutes
  2. Child: 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
3. Vasopressin (not commonly used in community EDs and out of 2015 AHA guidelines)
  1. Adult: 40 units for 1 dose
4. Atropine is no longer recommended as of 2010 guidelines
  1. Was previously given at 1 mg IV for Asystole or Slow PEA
Other experimental measures
1. Vasopressin 20 units
  1. No longer part of AHA pulseless algorithm guidelines as of 2015 (prior alternative to epi)
  2. Vasopressin is given in addition to Epinephrine per protocol
    1. Vasopressin may be better at maintaining brain perfusion
    2. Epinephrine appears better at achieving ROSC
  3. Consider Vasopressin when low End-Tidal CO2 (e.g. 20) despite high quality CPR
  4. Early studies suggest improved survival
  5. Orman and Weingart in Herbert (2015) EM:Rap 15(1): 14-6
  6. Mentzelopoulus (2013) JAMA 310(3): 270-9 [PubMed]
2. Esmolol
  1. May be considered for refractory Ventricular Fibrillation in adults (based on small study)
  2. Dose: 500 mcg/kg (folllowed by infusion at 0-100 mcg/kg/min)
  3. Driver (2014) Resuscitation 85(10): 1337-41 +PMID:25033747 [PubMed]
3. Double sequential external Defibrillation
  1. Two Defibrillators with pads right-left, front-back deliver maximal shock simultaneously
  2. May be considered in refractory Ventricular Fibrillation in adults (esp. obese)
  3. Cheskes (2023) Intensive Care Med 49(4):455-7 +PMID: 36754880 [PubMed]
Other measures to avoid unless specifically indicated
1. Empiric Calcium Administration (without specific indication)
  1. Routine Calcium administration is associated with worse outcomes in out of hospital Cardiac Arrest
  2. Messias Hirano Padrao (2022) Resusc Plus 12:100315 +PMID: 36238582 [PubMed]

Management
Rhythm - Pulse Present - Unstable in adults and children (ACLS and PALS)

See Reversible Causes of Cardiopulmonary Arrest (5H5T)
Indications for Unstable Status
1. Chest Pain
2. Hypotension or other signs of shock
3. Altered Level of Consciousness
Bradycardia (symptomatic with hemodynamic instability)
1. See Unstable Bradycardia
2. Perform CPR in children for Heart Rate <60/min with signs of hypoperfusion
3. Atrioventricular Block (AV Block): Mobitz 2 or third degree
  1. Transcutaneous Pacing
  2. Prepare for Transvenous Pacing
4. No AV Block (or first degree or Wenckebach)
  1. Adults
    1. Atropine 0.5 mg IV (may repeat up to a cummulative total of 3 mg)
    2. Transcutaneous Pacing
    3. Chronotropes (alternative to Transcutaneous Pacing)
      1. Epinephrine 2-10 mcg/min
      2. Dopamine 2-10 mcg/kg/min
  2. Children
    1. Epinephrine 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
    2. Atropine 0.02 mg/kg and may repeated once (min to max dose: 0.1 mg to 0.5 mg)
      1. Indicated if increased vagal tone or primary Atrioventricular Block
    3. Transcutaneous Pacing
Tachycardia: Synchronized Cardioversion
1. See Unstable Tachycardia
2. Conscious Sedation if no delays
3. Adults
  1. Atrial Arrhythmia
    1. Start at 200 joules biphasic (per ACLS 2025)
    2. Prior guidelies: 120 J biphasic for PSVT, Atrial Flutter; 120 J for Atrial Fibrillation
  2. Ventricular Arrhythmia
    1. Monomorphic Ventricular Tachycardia
      1. Synchronized Cardioversion or Defibrillation 200 J biphasic, 360 J monophasic
    2. Polymorphic Ventricular Tachycardia
      1. Immediate Defibrillation at 200 J biphasic, 360 J monophasic (ACLS 2025)
4. Children
  1. Initial: 0.5 to 1 J/kg
  2. Refractory: 2 J/kg

Management
Rhythm - Pulse Present - Stable - Bradycardia in adults and children (ACLS and PALS)

Indicated if unstable criteria above not met
Bradycardia
1. Evaluate for Sinus Bradycardia causes
2. Observe for change in status

Management
Rhythm - Pulse Present - Stable - Tachycardia in Adults (ACLS)

Indicated if unstable criteria above not met
See Reversible Causes of Cardiopulmonary Arrest (5H5T)
Wide Complex Tachycardia (QRS wider than 0.12 msec)
1. Regular Wide Complex Tachycardia
  1. Start with Adenosine 6 mg IV (may repeat with 12 mg IV)
    1. Benign and slows the rhythm for interpretation
    2. Helps to differentiate SVT with aberrancy from VT
  2. Supraventricular Tachycardia with Aberrancy
    1. Treat as Regular Narrow Complex Tachycardia (see below)
  3. Ventricular Tachycardia
    1. Synchronized Cardioversion
    2. Amiodarone 150 mg IV over 10 min (followed by infusion)
      1. Procainamide is more effective than Amiodarone
      2. Procainamide may be preferred if no CHF or Prolonged QT Interval
    3. Alternative Antiarrhythmics
      1. Procainamide (if no CHF and no Prolonged QT Interval)
      2. Sotalol 100 mg (1.g mg/kg) IV over 5 min (if no Prolonged QT Interval)
2. Irregular Wide Complex Tachycardia
  1. Atrial Fibrillation with WPW
    1. Amiodarone 150 mg IV
    2. Consult with cardiology
    3. Avoid Beta Blockers, Calcium Channel Blockers, Digoxin, Adenosine
  2. Atrial Fibrillation with aberrancy
    1. Treat as Irregular Narrow Complex Tachycardia (see below)
  3. Torsades de Pointes
    1. Magnesium 1-2 grams IV
    2. Synchronized Cardioversion (or Defibrillation if unable to sync)
    3. Over-drive Transcutaneous Pacing
Narrow Complex Tachycardia
1. Regular Narrow Complex Tachycardia
  1. Vagal Maneuvers
  2. Adenosine 6 mg and may repeat at 12 mg dose
    1. Conversion with Adenosine suggests Paroxysmal Supraventricular Tachycardia (PSVT)
    2. Recurrence can be treated with Adenosine, Diltiazem or Lopressor
  3. Rate control
    1. Rate control with Diltiazem or Lopressor (see below)
    2. Refractory to Adenosine causes
      1. Atrial Flutter
      2. Ectopic Atrial Tachycardia
      3. Junctional Tachycardia
2. Irregular Narrow Complex Tachycardia
  1. Occurs with Atrial Fibrillation, Atrial Flutter or Multifocal Atrial Tachycardia (MAT)
  2. Avoid Adenosine (risk of Ventricular Fibrillation)
  3. Rate control
    1. Diltiazem
      1. Bolus 1: 20 mg (0.25 mg/kg) IV bolus over 2 min
      2. Bolus 2: 25 mg (0.35 mg/kg) IV bolus over 2 min
        Administer if indicated, and at least 15 min after first
      3. Drip: 10 mg/hour (typical range: 5-15 mg/hour)
    2. Metoprolol (Lopressor)
      1. Avoid in acute CHF or COPD exacerbation
      2. Bolus: 2.5 to 5 mg IV every 2-5 min (maximum 15 mg in 15 min)

Management
Rhythm - Pulse Present - Stable - Tachycardia in Children (PALS)

Indicated if unstable criteria above not met
See Reversible Causes of Cardiopulmonary Arrest (5H5T)
Wide Complex Tachycardia (QRS wider than 0.09 msec; contrast with 0.12 in adults)
1. Consider Ventricular Tachycardia
2. Unstable Wide Complex Tachycardia
  1. See Unstable Tachycardia above
  2. Synchronized Cardioversion
3. Stable, regular Wide Complex Tachycardia
  1. Consider SVT with aberrancy if monomorphic QRS and regular rhythm
  2. Adenosine
    1. Do not use Adenosine if rhythm irregular (risk of WPW or rhythm degeneration)
    2. First: 0.1 mg/kg (maximum 6 mg)
    3. Second: 0.2 mg/kg (maximum 12 mg)
4. Stable, irregular or refractory Wide Complex Tachycardia
  1. Precautions
    1. Consult cardiology about recommended Antiarrhythmic
    2. Avoid combining Amiodarone and Procainamide
  2. Agents
    1. Amiodarone 5 mg/kg over 20-60 minutes
    2. Procainamide 15 mg/kg IV over 30-60 minutes
Narrow Complex Tachycardia (QRS 0.09 msec or less; contrast with 0.12 in adults)
1. Sinus Tachycardia
  1. Findings
    1. Normal P Waves, variable R-R with a constant PR Interval
    2. Heart Rate <180 in children (<220 in infants)
  2. See Sinus Tachycardia
  3. Indentify and treat underlying cause
2. Supraventricular Tachycardia
  1. Findings
    1. Abnormal or absent P Waves
    2. Constant Heart Rate >180 in children (>220 in infants)
  2. Vagal Maneuvers if no delays
  3. Adenosine (if regular rhythm)
    1. Do not use Adenosine if rhythm irregular (risk of WPW or rhythm degeneration)
    2. First: 0.1 mg/kg (maximum 6 mg)
    3. Second: 0.2 mg/kg (maximum 12 mg)
  4. Synchronized Cardioversion
    1. Indicated for irregular rapid rhythm or SVT refractory to above measures

Management
Additional measures

See Reversible Causes of Cardiopulmonary Arrest
See Post-Cardiac Arrest Care
Post-arrest pronouncement in the emergency department
1. Consider a moment of silence for deceased patient at end of Resuscitation attempt
2. Strayer in Herbert (2018) EM:Rap 18(2): 3

Resources

Cardiopulmonary Resuscitation Guidelines
1. http://www.circulationaha.org

References

Trauma
1. (2008) ATLS Manual, American College of Surgeons
2. Majoewsky (2012) EMR:RAPC3 2(1): 1-2
Cardiopulmonary Resuscitation Guidelines
1. Mace (2013) Crit Dec Emerg Med 27(1): 11-20
2. Mace (2013) Crit Dec Emerg Med 27(2): 2-10
3. (2010) Guidelines for CPR and ECC [PubMed]
4. (2005) Circulation 112(Suppl 112):IV [PubMed]
5. (2000) Circulation, 102(Suppl I):86-9 [PubMed]