22/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate minutes followed by 1 mg/min drip for six hours, and then 0.5 mg/min) but may cause conversion to sinus rhythm, which may result in embolic injury if the atrial fibrillation was not short lived [78]. For atrial fibrillation associated with acute heart failure, amiodarone or digoxin may be used for rate control. Treatment of MAT includes correction of possible precipitants, such as hypokalemia and hypomagnesemia. The ACLS Guidelines recommend consultation with a cardiologist for these arrhythmias. Cardioversion of stable patients with irregular narrow complex tachycardias should not be undertaken without considering the risk of embolic stroke. If the duration of atrial fibrillation is known to be less than 48 hours or the patient has been receiving long-term therapeutic anticoagulation (eg warfarin with an international normalized ratio [INR] known to be therapeutic or a novel oral anticoagulant with good adherence), the risk of embolic stroke is low, and the clinician may consider electrical or chemical cardioversion [79]. A number of medications can be used for chemical cardioversion, and the best drug varies according to clinical circumstance. The questions of whether chemical cardioversion is appropriate and which agent to select are reviewed separately. Regular wide complex A regular wide-complex tachycardia is generally ventricular in etiology ( algorithm 5). Aberrantly conducted SVTs may also be seen. Because differentiation between VT and SVT with aberrancy can be difficult, assume VT is present. Treat clinically stable undifferentiated wide-complex tachycardia with antiarrhythmics or planned synchronized cardioversion [36,54,55]. In cases of regular wide-complex tachycardia with a monomorphic QRS complex, adenosine may be used for diagnosis and treatment. Do not give adenosine (or other AV nodal blocking medications) to patients who are unstable or manifest wide-complex tachycardia with an irregular rhythm or a polymorphic QRS complex. SVT with aberrancy, if definitively identified (eg, old ECG demonstrates bundle branch block), may be treated in the same manner as narrow- complex SVT, with vagal maneuvers, adenosine, or rate control (see 'Irregular narrow complex' above). Adenosine is likely to slow or convert SVT with aberrancy. Dosing is identical to that used for SVT. Adenosine also terminates some cases of VT, particularly those that originate in the left or right ventricular outflow tracts [80]. Thus, adenosine responsiveness cannot be used to confirm a diagnosis of SVT or to exclude VT. (See 'Regular narrow complex' above.) Other antiarrhythmic drugs that may be used to treat stable patients with regular wide-complex tachycardia include procainamide (20 to 50 mg/min IV), amiodarone (150 mg IV given over 10 minutes, repeated as needed to a total of 2.2 g IV over the first 24 hours), and sotalol (100 mg IV over five minutes). A procainamide infusion continues until the arrhythmia is suppressed, the patient becomes hypotensive, the QRS widens 50 percent beyond baseline, or a maximum dose https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 23/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate of 17 mg/kg is administered. Procainamide and sotalol should be avoided in patients with a prolonged QT interval. If the wide-complex tachycardia persists despite pharmacologic therapy, cardioversion may be needed. The ACLS Guidelines recommend expert consultation for all patients with wide complex tachycardia. Irregular wide complex A wide-complex, irregular tachycardia may be atrial fibrillation with preexcitation (eg, Wolf Parkinson White syndrome), atrial fibrillation with aberrancy (bundle branch block), or polymorphic VT/torsades de pointes ( algorithm 5) [36,54,55]. Use of AV nodal blockers in wide-complex, irregular tachycardia of unclear etiology may precipitate VF and death and is contraindicated. Such medications include beta blockers, calcium channel blockers, digoxin, and adenosine. To avoid inappropriate and possibly dangerous treatment, the ACLS Guidelines suggest assuming that any wide-complex, irregular tachycardia is caused by preexcited atrial fibrillation. Patients with a wide-complex, irregular tachycardia caused by preexcited atrial fibrillation usually manifest extremely fast heart rates (generally over 200 beats per minute) and require immediate synchronized electric cardioversion. In cases where electric cardioversion is ineffective or unfeasible, or atrial fibrillation recurs, antiarrhythmic therapy with procainamide, amiodarone, or sotalol may be given. The ACLS Guidelines recommend expert consultation for all patients with wide-complex tachycardia. Dosing for antiarrhythmic medications is described above. (See 'Regular wide complex' above.) Treat polymorphic VT with emergency defibrillation. Interventions to prevent recurrent polymorphic VT include correcting underlying electrolyte abnormalities (eg, hypokalemia, hypomagnesemia) and, if a prolonged QT interval is observed or thought to exist, stopping all medications that increase the QT interval. Magnesium sulfate (2 to 4 g IV administered via rapid IV bolus followed by a maintenance infusion) can be given to prevent polymorphic VT associated with familial or acquired prolonged QT syndrome [81]. A clinically stable patient with atrial fibrillation and a wide QRS interval known to stem from a preexisting bundle branch block (ie, old ECG demonstrates preexisting block with the same QRS morphology) may be treated in the same manner as a narrow-complex atrial fibrillation. Alternative methods for medication administration Although vascular access via the IO route is safe and more easily initiated in the setting of cardiac arrest, administration of medication via the IV route produces more favorable outcomes. Nevertheless, when IV access cannot be established, or its theoretical benefit is mitigated by the time and resources necessary to initiate it, IO lines have been found to be safe and effective according to observational studies [36,54,55,82]. https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 24/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate One large observational study reported inferior outcomes among victims of out-of-hospital cardiac arrest receiving IO access, but this finding could have been related to other variables in these patients [83]. More investigation is needed to assess whether proximal humeral IO placement versus pretibial placement results in enhanced medication delivery and survival. Medication doses for IO administration are identical to those for IV therapy. If neither IV nor IO access can be established, some medications may be given via the tracheal tube. (See "Intraosseous infusion", section on 'Indications'.) Multiple studies have demonstrated that lidocaine, epinephrine, atropine, vasopressin, and naloxone are absorbed via the trachea [36]; however, the serum drug concentrations achieved using this route are unpredictable. If the patient already has peripheral, IO, or central venous access, these are always the preferred routes for drug administration. When unable to obtain such access expeditiously, one may use the endotracheal tube while attempting to establish vascular or IO access. At no point should excellent CPR be interrupted to obtain vascular access. Doses for tracheal administration are 2 to 2.5 times the standard IV doses, and medications should be diluted in 5 to 10 mL of sterile water or normal saline before injection down the tracheal tube. USE OF ULTRASOUND AND ECHOCARDIOGRAPHY Bedside echocardiography must never interfere with resuscitation efforts and should not interrupt or delay resumption of cardiopulmonary resuscitation (CPR) except in cases where the ultrasound is being obtained strictly to confirm absence of cardiac activity when a decision to terminate resuscitative efforts is imminent. The 2020 update of the ACLS Guidelines suggests that point-of-care ultrasound and echocardiography be employed to help identify reversible causes of cardiac arrest (eg, cardiac tamponade, tension pneumothorax, pulmonary embolism) and to assist in the identification of return of spontaneous circulation (ROSC) [11,84,85]. (See 'Termination of resuscitative efforts' below.) According to a systematic review of 12 small trials, most of which studied convenience samples of patients with sudden cardiac arrest (n = 568), bedside echocardiography may be helpful to predict ROSC [86]. In this review, the pooled sensitivity and specificity of echocardiography to predict ROSC were 91.6 and 80 percent, respectively (95% CI for sensitivity 84.6-96.1 percent; 95% CI for specificity 76.1-83.6 percent). Of the 190 patients found to have cardiac activity, 98 (51.6 percent) achieved ROSC, whereas only 9 (2.4 percent) of the 378 with cardiac standstill did so. Other studies have reached similar conclusions about the rarity of ROSC in cases with cardiac https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 25/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate standstill on ultrasound [87-89]. Echocardiography should not be the sole basis for terminating resuscitative efforts but may serve as an adjunct to clinical assessment. POST-RESUSCITATION CARE The ACLS Guidelines recommend a combination of goal-oriented interventions provided by an experienced multidisciplinary team for all cardiac arrest patients with return of spontaneous circulation (ROSC) [11,13,54,90]. Important objectives for such care include: Optimizing cardiopulmonary function and perfusion of vital organs Managing acute coronary syndromes Implementing strategies to prevent and manage organ system dysfunction and brain injury Management of the post-cardiac arrest patient is reviewed separately. (See "Initial assessment and management of the adult post-cardiac arrest patient" and "Intensive care unit management of the intubated post-cardiac arrest adult patient".) TERMINATION OF RESUSCITATIVE EFFORTS Criteria for determining whether to stop Determining when to stop resuscitation efforts in cardiac arrest patients is difficult, and little high-quality evidence exists to guide decision-making [91]. Furthermore, decision-making may vary depending on clinical circumstances, including settings discussed in the following topics. (See "Drowning (submersion injuries)" and "Accidental hypothermia in adults" and "Electrical injuries and lightning strikes: Evaluation and management" and "Initial management of the critically ill adult with an unknown overdose".) Physician survey data and clinical practice guidelines suggest that factors influencing the decision to stop resuscitative efforts include [92-96]: Duration of resuscitative effort >30 minutes without a sustained perfusing rhythm Unwitnessed collapse with an initial ECG rhythm of asystole Prolonged interval between time of collapse and initiation of cardiopulmonary resuscitation (CPR) Patient age, severe comorbid disease, or prior functional dependence More objective endpoints of resuscitation have been proposed. Of these, the best predictor of outcome may be the end-tidal carbon dioxide (EtCO ) level following 20 minutes of resuscitation 2 [97-99]. EtCO values are a function of carbon dioxide (CO ) production and venous return to the 2 2 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 26/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate right heart and pulmonary circulation. A very low EtCO (<10 mmHg) following prolonged 2 resuscitation (>20 minutes) is a sign of absent circulation and a strong predictor of acute mortality [97-99]. It is crucial to note that low EtCO levels may also be caused by a misplaced 2 endotracheal tube, and this possibility needs to be excluded as soon as the low CO level is 2 identified and before the decision is made to terminate resuscitative efforts. (See "Carbon dioxide monitoring (capnography)".) Resuscitation in the emergency department does not appear to be superior to field resuscitation by emergency medical services (EMS) personnel. Therefore, EMS personnel should not transport all victims of sudden cardiac arrest to the hospital if further resuscitation is deemed futile [100,101]. Large retrospective cohort studies have assessed criteria (basic life support [BLS] and ALS) for the prehospital termination of resuscitative efforts in cardiac arrest, initially described in the OPALS study [102,103]. Both BLS and ALS criteria demonstrated high specificity for identifying out-of-hospital cardiac arrest patients with little or no chance of survival. Studies of another clinical decision rule suggest that it too accurately predicts survival and would reduce unnecessary transports substantially if implemented [100,104]. The 2020 update of the ACLS guidelines suggests that point-of-care ultrasound and echocardiography may be employed to help identify reversible causes of cardiac arrest but should not be employed for prognostication. (See 'Use of ultrasound and echocardiography' above.) One simple and potentially useful set of criteria for determining the futility of resuscitation following out-of-hospital cardiac arrest is the following: Arrest not witnessed by EMS personnel Non-shockable initial cardiac arrhythmia (eg, asystole, pulseless electrical activity [PEA]) No return of spontaneous circulation (ROSC) prior to administration of third 1 mg dose of epinephrine These criteria were developed by researchers based on data from 6962 cardiac arrest patients included in two large registries (Paris and King County, Washington) and a major multicenter randomized trial [105]. Of the 2800 patients evaluated who met all three criteria, only one survived (survival rate 0 percent; 95% CI 0.0-0.5 percent). Specificity and the positive predictive value for these criteria were both 100 percent. Discussion with family members Guidance for breaking bad news or holding difficult discussions with the patient s family is provided separately. (See "Palliative care for adults in the ED: Goals of care, communication, consultation, and patient death", section on 'Communicating difficult news'.) https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 27/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Basic and advanced cardiac life support in adults".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topic (see "Patient education: Ventricular fibrillation (The Basics)") SUMMARY AND RECOMMENDATIONS Key principles and access to algorithms High-quality chest compressions and early defibrillation for treatable arrhythmias remain the cornerstones of basic life support (BLS) and advanced cardiac life support (ACLS). The most recent versions of the ACLS algorithms can be accessed online; access to copies within UpToDate is provided below. (See 'Excellent basic life support and its importance' above.) Cardiac arrest (ventricular fibrillation [VF], pulseless ventricular tachycardia [VT], asystole, pulseless electrical activity) ( algorithm 3) Bradycardia with pulse ( algorithm 4) Tachycardia with pulse ( algorithm 5) https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 28/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Team performance during resuscitation Teams providing ACLS perform better when there is a single designated leader who asks for and accepts helpful suggestions from members of the team, and when the team practices clear, closed-loop communication. (See 'Resuscitation team management' above.) Initial interventions Begin excellent cardiopulmonary resuscitation (CPR) immediately for any patient with suspected cardiac arrest. Excellent chest compressions have few interruptions, are delivered at the correct rate and depth, and allow complete chest recoil ( table 1). Secondary interventions include performing ventilations, administering oxygen, establishing vascular access, initiating appropriate monitoring (cardiac, oxygen saturation, waveform end-tidal carbon dioxide [EtCO ]), and obtaining an 2 electrocardiogram (ECG). (See 'Initial management and ECG interpretation' above.) During initial life support of adults, high-quality chest compressions take priority over ventilation (circulation, airway, breathing [C-A-B]). When ventilating the patient in cardiac arrest, give 100 percent oxygen, use low respiratory rates (approximately six to eight breaths per minute), and avoid hyperventilation, which is harmful. Ventilation using a bag- valve-mask (BVM) or supraglottic airway is preferred when possible. (See 'Airway management' above.) ECG interpretation For the purposes of ACLS, ECG interpretation is guided by three questions: Is the rhythm fast or slow? Are the QRS complexes wide or narrow? Is the rhythm regular or irregular? Arrhythmia management The basic approach and important aspects of management for each arrhythmia covered by the ACLS Guidelines are discussed in the text and summarized in the accompanying algorithms. Patients with VF or VT are defibrillated as rapidly as possible. For patients with effective respiration and a palpable pulse, treatment is determined by the ventricular rate (tachycardiac or bradycardia) and clinical assessment of overall stability (see 'Management of specific arrhythmias' above and 'Medications used during CPR' above): Cardiac arrest (VF, pulseless VT, asystole, pulseless electrical activity) ( algorithm 3) (see 'Pulseless patient in sudden cardiac arrest' above) A single biphasic defibrillation is the treatment for VF or VT. CPR should be performed until the defibrillator is charged and resumed immediately after the shock is given https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 29/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate without pausing to recheck a pulse. Bradycardia with pulse ( algorithm 4) (see 'Bradycardia' above) Tachycardia with pulse ( algorithm 5) (see 'Tachycardia' above) Use of UpToDate is subject to the Terms of Use. REFERENCES 1. DeBard ML. The history of cardiopulmonary resuscitation. Ann Emerg Med 1980; 9:273. 2. Highlights of the History of Cardiopulmonary Resuscitation (CPR). American Heart Associati on 2006. www.americanheart.org (Accessed on March 01, 2007). 3. Hermreck AS. The history of cardiopulmonary resuscitation. Am J Surg 1988; 156:430. 4. Panchal AR, Bartos JA, Caba as JG, et al. 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