Cardiac arrest algorithm |


  1. Rashhh says

    Hi! I’m a little bit confused with how the Epinephrine and Amiodarone works in timing. Correct me if I’m wrong.

    Initiate CPR; FIRST rhythm check > PEA/ASY > will give epinephrine.

    If the FIRST rhythm check is pVT/VF, shock the patient. If after the SECOND rhythm check is pVT/VF, we will give Epinephrine. After THIRD shock, if it is still pVT/VF, Amiodarone 300 mg should be given. Will I wait for another 3-5 minutes for the Epinephrine to be given AFTER the Amiodarone or just continue to give the Epi after 3-5 minutes from the first dose?

    7:30 START CPR
    7:32 pVT/VF ->>> 1ST SHOCK, CONTINUE CPR
    7:34 pVT/VF ->>> 2ND SHOCK + FIRST EPINEPHRINE while continuing CPR
    7:36 pVT/VF ->>> 3RD SHOCK + 300 MG AMIODARONE while continuing CPR
    7:38 pVT/VF ->>> 4TH SHOCK + 150 MG AMIODARONE while continuing CPR
    Will I give the Epinephrine around 7:37 to 7:39? Because that’s the 3-5 minutes window for the Epinephrine.
    Or will I wait another 3 minutes after the FIRST Amiodarone was given.

    Please correct my timeline. I would love to hear from you. Thank you so much!

    • ACLS says

      You are correct in saying that the epinephrine is first given after the second shock during CPR. After the first dose of epinephrine is administered, epinephrine is on its own timetable, and is given every 3 to 5 minutes regardless of everything else that is going on.

      Amiodarone 300 mg is given first after the third shock during CPR. The second bolus of amiodarone may be given after the 4the shock if it is needed for refractory VF or pVT.
      Kind regards,

  2. Lisa Chan says

    Hello, I have 2 questions:
    1) According to cardiac arrest algorithm, if a non-shockable rhythm converts to a shockable rhythm during rhythm shock, then we will follow the VF/ pVT pathway. Is it true that we can give enpinephrine/ amiodarone already after 1st shock (rather than give epinephrine after 2nd, give amiodarone after 3rd shock if we go over the VF/ pVT algorithm from the beginning)? If yes, how do we decide if we give epinephrine/ amiodarone first?
    2) Can you clarify if the dosage of MgSO4 for torsades de pointes is different for cardiac arrest and torsades de pointes with pulse? If yes, what are the dosages for each scenario?
    Thank you so much!

    • ACLS says

      1. This would be at the discretion of the physician that is leading the code. If the first dose of epinephrine was given when following the asystole/pea branch then it’s likely that a physician would carry on at the second administration of epi which would put the dose given after the first shock and the amiodarone given after the 2nd shock.

      2. Dosage is the same. The recommended initial dose of magnesium is a slow 2 g IV push. An infusion of 1 gm to 4 gm/hr should be started to keep the magnesium levels greater than 2 mmol/L. Once the magnesium level is greater than 3 mmol/L, the infusion can be stopped

      Kind regards,

  3. Simona Dumitru says

    Do you stop CPR for advanced airway, endotracheal tube for exemple? Thank you. ( As usual, like years before, super informed and very good structured informations. Thanks again for your admirable work!)

  4. Tera Messner says

    Is there a place within your site that I can click on the various algorithms to print for studying purposes? Please let me know. Thanks.

  5. connie says

    So say you gave after fourth shock -150mg amiodarone- and after another cycle of cpr you have administered epi after 5th shock. but now 6th shock comes around do you still give 150 mg amiodarone or is the dose higher or even less than this? Or will you start to infuse the drug after the of 150 mg amiodarone and your coming up to a time when you want to give it again?

    • ACLS says

      During cardiac arrest, the first dose of amiodarone IV push is 300 mg. The second dose would be 150 mg. These two doses are the only doses that are given during cardiac arrest. If cardiac arrest continues to be refractory in spite of all efforts up to this point it is unlikely that giving more amiodarone will reverse the problem. If the patient does experience ROSC and tachyarrhythmias persist then and amiodarone infusion would be started.

      Kind regards,

  6. Zhilam Zia says

    I like to thank you very much for nice clarification about treatment of VF. Would you please let me know about any role of IV amiodarone in hemodynamically unstable VT with pulse if Synchronized DC shock can not be given due to any reason ?
    Secondly, which one is best in Stable VT with pulse, IV amiodarone or procainamide ? Thanks and best regards.

    • ACLS says

      Amiodarone is the first recommended antiarrhythmic for the treatment of stable and unstable VT. There are no major reasons for withholding amiodarone unless there has been a previous negative reaction with the medication.

      I personally have not seen procainamide used in years so I cannot speak specifically about it use. Amiodarone is the antiarrhythmic of choice.

      Kind regards,

  7. Elizabeth Owens says

    I was wondering why the dosing interval is every 3-5 minutes other than that’s what the ACLS says?

    • Jeff with admin. says

      Since the half-life of epinephrine is 5-10 minutes you give the epinephrine every 3-5 minutes. This keeps the epinephrine at peak levels. Giving it outside of the 3-5 minute parameter allows the epinephrine levels in the blood to be either higher than needed or lower that needed. Kind regards, Jeff

      • Christopher P Kenner says

        If epi was administered initially via IO, a second dose was 7 minutes later, and a third was also given at 7 minutes, what if any, contraindications would thete be?

      • ACLS says

        There would not be any contraindication, however, the epinephrine half-life is two minutes. Therefore, there would be a great potential for the blood levels of epinephrine would drop to low between the doses. This is why epinephrine doses are set to be given every 3–5 min.

        Kind regards,

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