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Free · AHA 2020 + 2023 focused updates · Quick reference

Code blue, walked through. Fast.

Adult BLS, ACLS (cardiac arrest, bradycardia, tachycardia, post-arrest), and pediatric PALS algorithms. For learning and quick reference between actual training — does NOT substitute for AHA certification.

Adult Basic Life Support (BLS)

  1. Scene safety — ensure environment is safe.
  2. Check responsiveness — tap shoulder, shout. Simultaneously check breathing & pulse (carotid for adult, ≤ 10 sec).
  3. Activate emergency response — call code blue, get AED + crash cart.
  4. Begin CPR:
    Compressions: heel of hand on lower half of sternum, second hand on top, arms straight. Depth 2-2.4 in (5-6 cm), rate 100-120/min, complete recoil, minimize interruptions (< 10 sec).
    Ratio: 30:2 until advanced airway, then continuous compressions + 1 breath q6 sec.
  5. Apply AED ASAP: power on → attach pads (upper R chest + lower L axilla) → let it analyze → deliver shock if advised → resume compressions IMMEDIATELY after shock.
  6. Rotate compressor every 2 min (or 5 cycles) to maintain quality.
  7. Continue until ROSC, ACLS team arrives, or termination criteria met.
High-quality CPR fundamentals (AHA 2020): push hard, push fast, full recoil, minimize interruptions, avoid excessive ventilation. Quality > perfect ratios.

ACLS Cardiac Arrest Algorithm

Step 1 — Confirm arrest, start CPR, attach monitor

Pulseless? → CPR + O2 + monitor/defib pads. Establish IV/IO access.

Step 2 — Identify rhythm: shockable or not

SHOCKABLE: VF or pulseless VT
  1. Shock (biphasic 120-200 J, monophasic 360 J) → resume compressions immediately.
  2. CPR × 2 min. IV/IO access if not yet.
  3. Rhythm check — if still shockable: Shock → Epinephrine 1 mg IV/IO q3-5 min → CPR × 2 min.
  4. Rhythm check — if still shockable: Shock → Amiodarone 300 mg IV/IO (or Lidocaine 1-1.5 mg/kg) → CPR × 2 min.
  5. Repeat: Amio 150 mg IV/IO for next dose if needed; Epi q3-5 min throughout.
  6. Treat reversible causes (H's and T's).
NOT shockable: Asystole / PEA
  1. CPR × 2 min. IV/IO access. Epinephrine 1 mg IV/IO q3-5 min.
  2. Treat reversible causes urgently — PEA has more reversible etiologies than VF.
  3. Rhythm checks every 2 min. If rhythm becomes shockable, jump to shockable algorithm.
  4. Asystole confirmation: flat line in two leads. Increase amplitude before declaring.

H's and T's (reversible causes)

5 H's: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia.
5 T's: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary).

Advanced airway considerations

  1. Continuous compressions + 1 breath every 6 sec (10/min) once advanced airway placed.
  2. Confirm placement with waveform capnography (EtCO2) — gold standard.
  3. EtCO2 < 10 mmHg after 20 min of CPR predicts poor outcome.
  4. Don't interrupt compressions for intubation — drop LMA or supraglottic device if needed.

Bradycardia with a Pulse

Identify: HR < 50 with symptoms

Symptoms of unstable bradycardia: hypotension, AMS, ischemic chest pain, acute HF, signs of shock.

Treatment

  1. Monitor + ABCs + O2 if needed + IV access.
  2. Atropine 1 mg IV bolus (per AHA 2020 — dose increased from prior 0.5 mg). Repeat q3-5 min, max 3 mg total.
    Atropine likely INEFFECTIVE in: Mobitz Type II 2nd-degree AVB, 3rd-degree AV block, infranodal blocks. Go straight to pacing.
  3. If atropine fails OR contraindicated:
    • Transcutaneous pacing — set rate 60-80, start mA at 50 and increase until capture, sedate.
    • OR Dopamine infusion 5-20 mcg/kg/min
    • OR Epinephrine infusion 2-10 mcg/min
  4. Definitive: transvenous pacing, cardiology consult, treat underlying cause.

Tachycardia with a Pulse

Identify: HR > 150 with symptoms?

Unstable (hypotension, AMS, CP, HF, shock) → SYNCHRONIZED cardioversion immediately.
  • Narrow regular (SVT): 50-100 J → step up
  • Narrow irregular (AFib RVR): 120-200 J biphasic
  • Wide regular (VT with pulse): 100 J → step up
  • Wide irregular (polymorphic VT): treat as VF — DEFIB, not sync.

Stable — assess QRS width

Narrow regular (likely SVT):
  1. Vagal maneuvers (Valsalva, modified Valsalva — REVERT trial: leg lift after Valsalva ↑ success).
  2. Adenosine 6 mg IV rapid push followed by 20 mL NS flush + arm elevation. May repeat 12 mg, then 12 mg.
  3. If unsuccessful: beta-blocker OR calcium channel blocker.
Wide regular (likely VT or SVT with aberrancy):
  1. Treat as VT if uncertain: Amiodarone 150 mg IV over 10 min.
  2. Alternative: Procainamide 20-50 mg/min until arrhythmia suppressed or 17 mg/kg max.
  3. Cardiology consult — likely needs cardioversion or pacing.
Irregular (likely AFib): rate control with diltiazem/metoprolol; anticoagulation considerations per CHA2DS2-VASc.

Post-Cardiac Arrest Care (after ROSC)

  1. Optimize ventilation/oxygenation — target SpO2 92-98%, EtCO2 35-45 mmHg. Avoid hyper/hypoventilation.
  2. Hemodynamic optimization — target MAP ≥ 65; IVF + vasopressors as needed.
  3. 12-lead EKG to identify STEMI → emergent cath lab activation.
  4. Targeted temperature management (TTM): per AHA 2023 update, target 32-36°C (89.6-96.8°F) × 24 hr for comatose post-arrest patients (any rhythm). Then rewarm 0.25°C/hr. Avoid fever.
  5. Continuous EEG to detect seizures (5-20% of post-arrest patients).
  6. Glycemic control 144-180 mg/dL; avoid hypoglycemia.
  7. Neuroprognostication delayed ≥ 72 hr after rewarming (multimodal — clinical exam, EEG, NSE, imaging).
Family communication: early, honest, frequent. Outcomes uncertain in first 72 hr — avoid premature withdrawal-of-life-sustaining-therapy.

Pediatric Advanced Life Support (PALS)

Pediatric BLS — key differences from adult

  1. Compressions: 1/3 anterior-posterior chest depth (~1.5 in infant, ~2 in child).
  2. Ratio: 30:2 single rescuer; 15:2 two rescuers (infant and child).
  3. Pulse check site: brachial in infant; carotid or femoral in child.
  4. If sole rescuer + sudden witnessed arrest: activate emergency response FIRST. If unwitnessed arrest: 2 minutes CPR before leaving to call (more likely respiratory cause).

Pediatric cardiac arrest — most often respiratory

  1. VF/pulseless VT in pediatric: Shock 2 J/kg first, then 4 J/kg, then ≥ 4 J/kg (max 10 J/kg or adult dose).
  2. Epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000) q3-5 min.
  3. Amiodarone 5 mg/kg IV/IO for refractory VF/pulseless VT, may repeat × 2 (max 15 mg/kg/day).
  4. Address airway aggressively — most peds arrests start respiratory.

Length-based emergency dosing

When weight unknown: use Broselow tape for age/length-based dosing. Most accurate up to ~12 yr.

Recognize pediatric shock early

  1. Compensated: tachycardia + cool/mottled extremities + delayed cap refill + decreased UOP. BP may still be normal.
  2. Hypotensive (decompensated): SBP < 70 + (2 × age in years) for 1-10 yr. Late + ominous.
  3. Treat shock aggressively early — 20 mL/kg isotonic bolus, reassess, repeat ×3 if needed (per Surviving Sepsis pediatric guideline).

Code Meds Quick Reference

EpinephrineCardiac arrest: 1 mg IV/IO (10 mL of 1:10,000) q3-5 min. Anaphylaxis: 0.3-0.5 mg IM 1:1,000. Infusion: 0.01-0.5 mcg/kg/min.
AmiodaroneVF/pulseless VT: 300 mg IV/IO bolus, repeat 150 mg. Stable VT/SVT: 150 mg over 10 min → 1 mg/min × 6 hr → 0.5 mg/min × 18 hr.
AtropineBradycardia: 1 mg IV q3-5 min, max 3 mg total. NOT for high-degree AVB.
AdenosineSVT: 6 mg IV rapid push + 20 mL NS flush. Repeat 12 mg, then 12 mg. Half-life 10 sec.
LidocaineAlternative to amiodarone for VF/VT: 1-1.5 mg/kg IV/IO bolus, repeat 0.5-0.75 mg/kg q5-10 min, max 3 mg/kg.
Magnesium sulfateTorsades de pointes: 1-2 g IV over 5-20 min (push for arrest). Hypomagnesemia VF/VT: 1-2 g IV.
Calcium chlorideHyperkalemia, Ca-channel blocker tox, hypocalcemia: 0.5-1 g IV slow push. Central line preferred.
Sodium bicarbonateHyperkalemia, TCA OD, severe metabolic acidosis: 1 mEq/kg IV. NOT routine in arrest (delayed restoration of cellular pH).
NaloxoneOpioid OD: 0.4 mg IV/IM titrated, or 4 mg IN. Q2-3 min. Goal = respirations restored.
VasopressinRemoved from adult cardiac arrest (AHA 2015). Add-on to norepi in septic shock: 0.03-0.04 units/min fixed.
This is reference material, not certification. AHA BLS/ACLS/PALS certification requires hands-on training. Always follow your facility's specific code protocol. Doses listed are for ADULTS unless otherwise noted; pediatric dosing is weight-based — verify before administration.

References (APA)

American Heart Association. (2020). 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl 2), S337-S604. https://doi.org/10.1161/CIR.0000000000000916
Panchal, A. R., Bartos, J. A., Cabañas, J. G., Donnino, M. W., Drennan, I. R., Hirsch, K. G., ...Berg, K. M. (2020). Part 3: Adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl 2), S366-S468.
American Heart Association. (2023). 2023 focused updates on adult cardiopulmonary resuscitation and emergency cardiovascular care: Targeted temperature management. Circulation, 148.
Topjian, A. A., Raymond, T. T., Atkins, D., Chan, M., Duff, J. P., Joyner, B. L., ...Schexnayder, S. M. (2020). Part 4: Pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl 2), S469-S523.
Appelboam, A., Reuben, A., Mann, C., Gagg, J., Ewings, P., Barton, A., ...Benger, J. (2015). REVERT trial: Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias. Lancet, 386(10005), 1747-1753.