ACLS secondary survey: Respiratory arrest assessment

Last updated: June 27, 2023

Version control: Our ACLS, PALS & BLS courses follow 2020 American Heart Association Guidelines for CPR and ECC. American Heart Association guidelines are updated every five years. If you are reading this page after December 2025, please contact for an update. Version 2021.01.c

When identifying a pulseless victim, immediately call for help and activate the emergency response system. Start high-quality CPR by pushing at least 2 inches deep and allowing for complete chest recoil at a rate of 100 to 120 compressions per minute. Provide oxygen and attach a monitor/defibrillator as soon as possible. Minimize interruptions in compression. If there is no advanced airway established follow the 30:2 compression to ventilation ratio. If a shockable rhythm (VF/VT) is detected, deliver a shock per manufacturer’s guidelines. Resume chest compressions immediately following a shock and continue for 2 minutes. If no shock is required, continue chest compression for 2 minutes before checking a rhythm. Administer epinephrine 1 mg IV/IO every 3 to 5 minutes. Administer first dose of amiodarone 300 mg IV/IO or first dose lidocaine 1 to 1.5 mg/kg. The second dose of lidocaine is 0.5 to 0.75 mg/kg.

Consider an advanced airway. If an advanced airway, such as a supraglottic advanced airway or endotracheal airway is obtained, provide continuous chest compression and ventilations at 1 breath every 6 seconds or 10 breaths per minute. Avoid excessive ventilation and rotate compressors every 2 minutes. Monitor PETCO2 with quantitative waveform capnography and attempt to improve CPR quality with a PETCO2 for less than 10 mmHg. Second and subsequent shocks should be equal or higher doses than previous. Consider the reversible causes of Hs and Ts. Signs of return of spontaneous circulation are a pulse and blood pressure, sustained PETCO2 of > 35-45 mmHg or higher, and spontaneous arterial pressure waveforms. Follow post-cardiac arrest care.

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This page was written by on Jul 12, 2021.