Summary
Highlights
Begin with an initial impression. If the victim is unresponsive, proceed to BLS assessment. Check for response, breathing, and pulse for 5-10 seconds. If no pulse or breathing, immediately activate the code blue, call emergency services, and start high-quality CPR (100-120 compressions/minute, allow full chest recoil, avoid hyperventilation).
Upon AED/crash cart arrival, if the rhythm is shockable (VF/pVT), deliver the first shock immediately. Do not delay, as success rates decrease significantly. Follow manufacturer recommendations for joule settings (e.g., 360J monophasic, 120-200J biphasic). After defibrillation, immediately resume high-quality CPR. Establish IV/IO access and prepare epinephrine.
After 2 minutes of CPR, stop, switch roles, and analyze the rhythm. If still VF, deliver the second defibrillation (following manufacturer recommendations). Immediately resume high-quality CPR. Administer 1 mg of epinephrine, repeatable every 3-5 minutes. Consider advanced airway placement with capnography to confirm tube placement and monitor CPR quality. Prepare amiodarone.
After another 2 minutes, stop CPR, switch roles, and analyze. If still VF, deliver the third defibrillation and immediately resume high-quality CPR. Administer 300 mg IV push of amiodarone followed by a D5 water flush, or consider lidocaine (1-1.5 mg/kg). Begin to consider and address reversible causes (H's and T's).
The cycle continues with defibrillation (fourth, fifth, etc.) every two minutes if VF persists, followed by high-quality CPR. Epinephrine is given after even-numbered shocks (e.g., 2nd, 4th), and amiodarone after odd-numbered shocks (e.g., 3rd, 5th), with reduced amiodarone dose (150 mg) for subsequent administrations. This maintains a sequence of epinephrine and amiodarone every four minutes, aligned with the 3-5 minute recommendation for epinephrine.