Pulseless arrest

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This page is for adult patients. For pediatric patients, see: pulseless arrest (peds).


Algorithm for cardiac arrest (Adapted from ACLS 2010)
  1. Start CPR
  2. Give oxygen
  3. Attach monitor/defibrilator
  4. Rhythm shockable?

V-Fib and Pulseless V-Tach (Shockable)

  • Shock as quickly as possible and resume CPR immediately after shocking
    • Biphasic - 200J
    • Monophasic - 360 J
  • Give Epi 1mg if (shock + 2min of CPR) fails to convert the rhythm
  • Give antiarrhythmic if (2nd shock + 2min of CPR) again fails
    • 1st line: Amiodarone 300mg IVP with repeat dose of 150mg as indicated
    • 2nd line: Lidocaine 1-1.5mg/kg then 0.5-0.75mg/kg q5-10min
    • Polymorphic V-tach: Magnesium 2g IV, followed by maintenance infusion

Asystole and PEA (Non-Shockable)

  • Epi 1mg q3-5min
  • Three major mechanisms of PEA (3 & 3 Rule)
  1. Severe Hypovolemia
  2. Obstruction
  3. Pump Failure

Treatable ACLS Conditions (H's and T's)

PEA Evaluation by QRS

Differential based on QRS being narrow or wide and aided by ultrasound

QRS Narrow

Mechanical RV Problem – Ultrasound should show hyperdynamic LV and potential cause

QRS Widened

Metabolic LV Problem – Ultrasound should show hypokinetic LV


  • A (adjunct) - Place oropharyngeal airway
  • B (breathing) - place on Ventilator to assure slow ventilation rate (attach to BVM mask)
    • 10-12 bpm, 500cc tidal volume, Fio2 100%
  • C (compressions) - Switch out providers q pulse check; use metronome
    • 100-120 compressions/min
    • Compress to a depth between 2-2.4 inches (5-6 cm)
    • Allow full recoil between compressions
  • D - defibrillation
    • May be ok to shock during compressions if wearing gloves and using biphasic device[1]
    • Precharge prior to pulse & rhythm check to increase overall compression time
  • A (advanced airway)
    • Use LMA (NOT ET tube - no break in compressions required)
  • B (advanced breathing)
    • Connect LMA to Ventilator
      • Pressure control 20, RR 10, insp rate 1.5-2s
  • C (advanced circulation)
    • Place IO instead of central line
  • D (differential)

Refractory Ventricular Fibrillation

A patient is considered refractory after ≥3 defib, ≥3mg epinephrine, and 300mg amiodarone

The following therapies are largely based on case studies or case series

Dual Sequential Defibrillation[2] [3]

  1. Continue high quality CPR. Consider using devices such as LUCAS CPR to avoid ineffective CPR due to rescuer fatigue
  2. Place a second set of defib pads in an alternative location on the chest (anterior/posterior and right upper chest/left lateral)
  3. Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
  4. Continue CPR

Esmolol for Electrical Storm [4][5][6]

  1. Administer Esmolol bolus 500 mcg/kg IVP over 30 seconds (typical dose ranges 35-50 mg)
  2. If ROSC, initiate 50 mcg/kg/min infusion [7]
  3. Deliver 200J (or 360J if monophasic) simultaneously from both defibrillators
  4. Continue CPR

Consider holding further epinephrine (The Current State of Refractory VF)

Stellate Ganglion Nerve Block [8]

  1. Place probe over left anterior neck
  2. Identify thyroid gland, carotid artery, C6/C7, longus colli muscle, and prevertebral fascia
  3. Advance needle to stellate ganglion which is deep to prevertebral fascia and superficial to longus colli muscle
  4. Inject 1-2 ml of 1% lidocaine without epinephrine and observe dissection of the muscle and fascia layers to confirm placement
  5. With placement confirmed, inject the rest of the anesthetic for a total of 10ml of volume



  • Alteplase 0.6mg/kg IV push x1 given over 15 min (± heparin 5000 unit bolus), and then repeated 30 min after if still no ROSC[9]
    • Heparin may be bolused with tPA or after ROSC obtained
    • Max doses of 50mg may be as efficacious as 100mg
    • Consider at least 20min of CPR after last dose of tPA before ending code

Guidelines and Recommendations

  • ACLS 2010 does not yet recommend routine thrombolytics (Class III)
  • CHEST 2012 and ACLS 2010 recommends in acute PE or high suspicion[10]
    • Class IIc and Class IIa, respectively
    • 2 hr infusion time recommended over long, 24hr (CHEST Class IIc)

See Also

External Links


  1. Lloyd MS, Heeke B, Walter PF, and Langberg JJ. Hands-on defibrillation: an analysis of current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation. 2008; 117:2510-2514.
  2. Hoch DH et al. Double Sequential External Shocks for Refractory Ventricular fibrillation. JACC 1994; 23: 1141 – 5.
  3. Bero M et al. Changing the management of refractory ventricular fibrillation: the consideration of earlier utilization of dual sequential defibrillation. Am J Emerg Med. 2019 May 29. pii: S0735-6757(19)30359-6. doi: 10.1016
  4. Driver BE, Debaty G, Plummer DW, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with ventricular fibrillation. Resuscitation. 2014; 85(10):1337-1341.
  5. Boehm KM. First report of survival in refractory ventricular fibrillation after dual-axis defibrillation and esmolol administration. West J Emerg Med. 2016 Nov;17(6):762-765.
  6. Lee YH. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016 Oct;107:150-5. doi: 10.1016.
  7. Al-Khatib SM. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac arrest. Circulation. 2018 Sep 25;138(13):e272-e391. doi: 10.1161
  8. Margus, C, Correa, A, Cheung, W, et al. Stellate ganglion nerve block by point-of-care ultrasonography for treatment of refractory infarction-induced ventricular fibrillation. Ann Emerg Med. 2020;75(2):257–260.
  9. Böttiger BW et al. Lancet 2001;357:1583-5.
  10. Kearon C et al. Chest 2012; 141 (2)(suppl):e419s-e494s. Vanden Hoek TL et al. Circulation 2010; 122 (suppl):S829-S861.