Immediately: No response → alert the team/emergency services, have a defibrillator brought. No normal breathing → start chest compressions 30 : 2. Keep pauses as short as possible.
Quality of chest compressions
| Parameter | Target |
|---|---|
| Compression point | centre of the chest (lower half of the sternum) |
| Depth | 5–6 cm |
| Rate | 100–120 /min |
| Recoil | complete, hands stay on the chest |
| Ratio | 30 : 2 – with tracheal tube or SGA continuous compressions + 10 breaths/min (SGA with leak: back to 30 : 2) |
| Pause before shock | as short as possible (< 5 s), continue compressions while charging |
| Rescuer change | every 2 min (at each rhythm analysis) |
Sequence – 2-minute cycles
| Shockable (VF / pulseless VT) | Non-shockable (asystole / PEA) | |
|---|---|---|
| Rhythm analysis | every 2 min | every 2 min |
| Defibrillation | 1 shock, resume CPR immediately | – |
| Adrenaline (epinephrine) 1 mg | after the 3rd shock, then every 3–5 min | as early as possible, then every 3–5 min |
| Amiodarone | 300 mg after the 3rd shock, 150 mg after the 5th shock (alternative: lidocaine 100 mg / 50 mg) | – |
Amiodarone doses are based on the total number of shocks (3 and 5, respectively) – regardless of whether VF persists or recurs.
If the cardiac arrest is witnessed on a monitor (e.g. cardiac catheter laboratory) and the defibrillator is immediately available, up to three shocks in rapid succession may be delivered for initial VF/pVT. For the timing of adrenaline and amiodarone, this series of three counts as one shock.
- 1 mg i.v./i.o.[1]every 3–5 min · 0.1 mg/ml (1 mg made up to 10 ml with NaCl 0.9 %) · = 10 ml
Give diluted: 1 ml adrenaline 1 mg/ml + 9 ml NaCl 0.9 % = 10 ml (0.1 mg/ml) – 1 mg = 10 ml, then flush with NaCl 0.9 % (SmPC). Prefilled syringes 1 mg/10 ml likewise. Non-shockable rhythm – as early as possible. Shockable rhythm – after the 3rd shock.
- 300 mg i.v./i.o.[1]after the 3rd shock · 50 mg/ml (3 ml = 150 mg) · = 6 ml
- 150 mg i.v./i.o.[1]after the 5th shock · 50 mg/ml (3 ml = 150 mg) · = 3 ml
What counts is the total number of shocks (persistent or recurrent VF). Three stacked shocks in a witnessed arrest monitored on a cardiac monitor count as one shock.
Defibrillation
- Biphasic (rectilinear or truncated exponential): 1st shock at least 150 J.
- Pulsed biphasic: 1st shock 130–150 J (according to ERC 2025 ideally at least 150 J here as well, because the waveform is usually not labelled on the device – follow the manufacturer's information on the device).
- If the shock is unsuccessful and the device allows it: escalate the energy for subsequent shocks. Recommended device setting unknown: highest energy for all shocks.
- Refractory VF (persisting after 3 shocks): check correct pad position, select maximum energy, then consider a vector change (pads anterior–posterior).
- Double sequential defibrillation (second device, a.–l. + a.–p.): according to ERC 2025 not routinely – practical problems with two devices, limited evidence, trials ongoing. Pad check and vector change take priority; ILCOR 2025 considers it an option after ≥ 3 shocks (weak recommendation, low-certainty evidence) – not a standard procedure.
Access and airway
- Intravenous access first; intraosseous if i.v. access cannot be obtained rapidly (within 2 attempts).
- Stepwise airway approach: bag-mask → supraglottic airway (preferably a second-generation SGA with non-inflatable gel-like cuff, as per local protocol) or intubation – intubation only with a high success rate (> 95 % within ≤ 2 attempts) and a compression pause < 5 s.
- Waveform capnography mandatory: tube position, quality of compressions, sudden rise in etCO₂ as an indicator of ROSC (do not interrupt compressions on this basis alone – only together with other signs such as consciousness, purposeful movements, arterial pressure waveform). A low etCO₂ alone is not a criterion for stopping resuscitation.
- During resuscitation, give the highest possible oxygen concentration.
Reversible causes – "4 Hs and 4 Ts"
| 4 Hs | 4 Ts |
|---|---|
| Hypoxia | Tamponade (cardiac) |
| Hypovolaemia | Toxins |
| Hypo-/hyperkalaemia, metabolic | Thrombosis (coronary, pulmonary) |
| Hypo-/hyperthermia | Tension pneumothorax |
Point-of-care ultrasound to look for causes only by trained operators and without additional pauses. Consider eCPR as a rescue therapy in selected patients if conventional measures fail and a system is available – think of it early.
After ROSC – targets
| Domain | Target |
|---|---|
| Oxygenation | SpO₂ 94–98 % (as soon as it can be measured reliably); avoid hypoxaemia and hyperoxaemia |
| Ventilation | Normocapnia (PaCO₂ 35–45 mmHg) |
| Circulation | systolic > 100 mmHg or MAP > 60–65 mmHg |
| Temperature | actively prevent fever: ≤ 37.5 °C for at least 72 h in patients who remain comatose |
| Diagnostics | 12-lead ECG (repeat if needed); with persistent ST elevation emergency coronary angiography (PCI if indicated) |