›IO access if IV delayed
›Central access deferred until ROSC unless needed
Medications during VF or pulseless VT
›Vasopressor strategy
›Epinephrine IV or IO 1 mg
›Repeat every 3 to 5 minutes
›Timing typically after second shock
›Antiarrhythmic strategy for refractory VF or VT
›Amiodarone IV or IO 300 mg bolus
›Additional amiodarone IV or IO 150 mg bolus
›Lidocaine IV or IO 1 to 1.5 mg per kg if amiodarone unavailable or ineffective
›Additional lidocaine 0.5 to 0.75 mg per kg
›Maximum lidocaine 3 mg per kg
›Torsades focused therapy when polymorphic VT with prolonged QT
›Magnesium sulfate IV 2 g
›Over 1 to 2 minutes in arrest context
›Shock optimization
›Pad placement anterolateral or anteroposterior
›Ensure dry chest and remove medication patches
›No one touching patient during shock
›Immediate CPR resumption after shock without rhythm recheck
Refractory VF or VT options
›Escalation therapies local protocol dependent
›Vector change defibrillation pad repositioning
›Double sequential external defibrillation local protocol dependent
›Esmolol bolus and infusion for refractory VF local protocol dependent
›ECPR referral criteria and activation local protocol dependent
›Targeted interventions based on suspected cause
›Hyperkalemia treatment bundle
›Calcium chloride IV 1 g via central line when available
›Calcium gluconate IV 3 g via peripheral line alternative
›Regular insulin IV 10 units
›Dextrose IV 25 g if glucose not elevated
›Sodium bicarbonate IV 50 mmol if severe acidosis or hyperkalemia with ECG changes
›Tension pneumothorax
›Needle decompression local protocol dependent
›Finger thoracostomy local protocol dependent
›Cardiac tamponade
›Pericardiocentesis local protocol dependent
›Trauma surgery activation when traumatic
›Coronary thrombosis
›Cath lab activation after ROSC when STEMI or high suspicion local protocol dependent
›Stabilization after ROSC
›Target oxygen saturation 92 to 98 percent
›Avoid hyperventilation
›Maintain systolic blood pressure at least 90 mmHg local protocol dependent
›Treat hypotension with fluids and vasopressors
›Temperature management strategy local protocol dependent
›Pregnancy considerations
›Manual left uterine displacement during CPR after mid pregnancy
›Early obstetric activation
›Perimortem cesarean consideration local protocol dependent
›Pediatric considerations
›Defibrillation first shock 2 J per kg
›Subsequent defibrillation at least 4 J per kg
›Epinephrine IV or IO 0.01 mg per kg of 0.1 mg per mL concentration
›Amiodarone IV or IO 5 mg per kg bolus
›Hypothermia considerations
›Continue resuscitation until rewarmed local protocol dependent
›Limit shocks to 3 until temperature above 30 C local protocol dependent