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The ACLS Pulseless Arrest Algorithm is the most important algorithm to know when resuscitating adults. The algorithm steps through the assessment and management of a patient with no pulse who does not respond to the interventions of the primary survey, including an initial shock from an automated external defibrillator (AED). Pulseless VT is included in the algorithm with VF because they both require defibrillation and are both treated with high-energy unsynchronized shocks.

The Pulseless Arrest Algorithm picks up after the primary survey has already been conducted:

• The emergency response system has been activated.
• CPR is being performed.
• A defibrillator has been attached.
• The first shock has been given.

If you are using a monophasic defibrillator, give a single 360 Joule (J) shock. Use the same energy dose for subsequent shocks. If you are using a biphasic defibrillator, the effective dose range should be displayed on the face of the device. If the manufacturer did not include this information, deliver a 200 J shock for the first shock and an equal or higher dose for later shocks. If VF is initially terminated but returns later, use the same energy level that was successful in subsequent shocks.

Steps

Keep CPR going as consistently as you can. Interrupt chest compressions only for ventilation, rhythm checks, and actual shock delivery. Remind team members that they can prepare the drugs used ahead of time and minimize patient's time without CPR.

1. Begin 5 cycles of CPR (approximately 2 minutes) immediately after the first shock. Each cycle contains 30 chest compressions followed by 2 breaths.

2. Check the patient's rhythm in less than 10 seconds.

3. Clear patient for shock, taking less than 10 seconds.

• In a loud, firm voice, say, "I am going to shock on three. One. I'm clear."
• Then say, "Two. You are clear."
• Take a minute to look and make sure no team member is touching the patient or anything connected to the patient, particularly the person providing ventilations.
• Turn oxygen away from the patient's chest OR turn it off.
• Make sure the source of oxygen is removed from the patient when you clear to shock.
• Say, "Three, everybody clear." Check yourself one more time before you press the shock button.
• Press the shock button.

4. Immediately resume CPR for 5 cycles.

5. If IV/IO is available, administer a vasopressor during the CPR cycle (see drug administration below).

6. Check rhythm in less than 10 seconds, if possible.

7. If a shockable rhythm is present, give 1 shock.

• Continue CPR while the defibrillator is charging.
• Clear the patient for shock (see above directions).
• Deliver the shock.
• Resume CPR immediately after shock, 5 cycles.

Following the sequence in the algorithm is the best scientific approach to restore spontaneous circulation. The optimal number of times you should go through the CPR cycles and the shocks before starting drug therapy has not been determined.