Guide — Emergency Nursing
Cardiac Arrest & Resuscitation Guide
Chain of survival, high-quality CPR standards, shockable vs non-shockable rhythms, ACLS medications, reversible causes (Hs and Ts), and post-ROSC care for nurses.
11 min read · Emergency Nursing
Educational use only. Resuscitation protocols are based on AHA ACLS guidelines and are institution-specific. Complete formal ACLS certification for clinical competency. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Chain of Survival
| 1. Recognition & Activation | Recognize cardiac arrest; activate emergency response; get AED |
| 2. Early CPR | High-quality CPR: push hard, push fast, allow full recoil, minimize interruptions |
| 3. Rapid Defibrillation | Defibrillate shockable rhythms as quickly as possible — every minute without shock = 10% decrease in survival |
| 4. Advanced Life Support | ACLS interventions: IV/IO access, medications, advanced airway, identify reversible causes |
| 5. Post-Arrest Care | Targeted temperature management, hemodynamic optimization, coronary angiography (if indicated), neurological monitoring |
| 6. Recovery | Rehabilitation, cognitive/physical recovery support, psychological support |
High-Quality CPR Standards
| Element | Standard |
|---|---|
| Compression rate | 100–120 compressions/minute |
| Compression depth | Adults: ≥ 2 inches (5 cm), not exceeding 2.4 inches (6 cm). Children: at least 1/3 AP diameter of chest (~2 inches). Infants: ~1.5 inches. |
| Full chest recoil | Allow complete recoil between compressions — do not lean on chest. Prevents increased intrathoracic pressure that impedes venous return. |
| Minimize interruptions | Pause compressions < 10 seconds for rhythm check/defibrillation/airway. Pre-charge defibrillator while CPR continues. |
| Compression fraction | CCF ≥ 60% (compressions for at least 60% of resuscitation time) |
| Ventilation (without advanced airway) | 30:2 compression-to-ventilation ratio; 1 breath over 1 second; visible chest rise only |
| Ventilation (with advanced airway) | 1 breath every 6 seconds (10 breaths/min); do NOT pause compressions for ventilation; avoid hyperventilation (causes air trapping, reduces venous return) |
| Rescuer rotation | Switch compressors every 2 minutes (or sooner if fatigued) — quality drops after 2 min without rotation |
| Waveform capnography | PETCO₂ during CPR: target ≥ 10 mmHg (higher values correlate with better outcomes). Sudden rise in PETCO₂ = ROSC |
Shockable vs Non-Shockable Rhythms
SHOCKABLE — Defibrillate First
Ventricular Fibrillation (VF)
Chaotic, disorganized. No recognizable waveforms. No cardiac output. Defibrillate immediately.
Pulseless Ventricular Tachycardia (pVT)
Wide-complex, organized fast rhythm. No pulse. Defibrillate immediately.
Action: CPR until defibrillator ready → SHOCK → resume CPR immediately (2 min) → recheck rhythm
NON-SHOCKABLE — CPR + Address Causes
Pulseless Electrical Activity (PEA)
Organized electrical activity on monitor but NO pulse. Find and treat reversible cause (Hs and Ts).
Asystole
Flat line — no electrical activity. CPR + epinephrine + treat reversible causes. Confirm in 2 leads.
Action: CPR + epinephrine q3-5min + aggressively search for reversible causes
ACLS Medications
Epinephrine
1 mg IV/IO every 3–5 minutes
| Indication | All rhythms (VF, pVT, PEA, asystole) |
| Mechanism | Alpha-1 agonist: increases coronary and cerebral perfusion pressure during CPR |
| Timing | Can give epinephrine immediately for PEA/asystole. For shockable rhythms (VF/pVT): shock first, then epinephrine after 2nd shock. |
| NCLEX Focus | Epinephrine given q3-5min throughout resuscitation. Same dose for all rhythms. |
Amiodarone
300 mg IV/IO first dose; 150 mg second dose (if needed)
| Indication | Refractory VF or pulseless VT (shockable rhythms) — after ≥ 3 defibrillations |
| Mechanism | Class III antiarrhythmic — blocks K⁺ channels; prolongs action potential and refractory period |
| Timing | Give after 3rd shock if VF/pVT persists. Lidocaine is alternative if amiodarone unavailable. |
| NCLEX Focus | Amiodarone for REFRACTORY shockable rhythms (VF/pVT after 3 shocks). NOT used for PEA or asystole. |
Lidocaine
1–1.5 mg/kg IV/IO first dose; 0.5–0.75 mg/kg (max 3 doses)
| Indication | Alternative to amiodarone for refractory VF/pVT |
| Mechanism | Class Ib antiarrhythmic — blocks Na⁺ channels; stabilizes ventricular myocardium |
| Timing | Used when amiodarone is unavailable or post-ROSC for VT suppression |
| NCLEX Focus | Second-line to amiodarone for VF/pVT. Also used for post-ROSC VT maintenance. |
Sodium Bicarbonate
1 mEq/kg IV/IO
| Indication | NOT routine. Use for: known pre-existing hyperkalemia, TCA overdose, prolonged arrest (>10 min) with documented acidosis |
| Mechanism | Buffers metabolic acidosis; drives K⁺ into cells (hyperkalemia); alkalinizes sodium channel (TCA OD) |
| Timing | NOT first-line; give for specific indications only |
| NCLEX Focus | Sodium bicarb = TCA overdose (wide QRS), hyperkalemic arrest. Do NOT give routinely. |
Atropine
1 mg IV/IO (may repeat up to 3 mg total)
| Indication | NO LONGER recommended for asystole or PEA. Use only for SYMPTOMATIC BRADYCARDIA (not in arrest). |
| Mechanism | Anticholinergic: blocks vagal tone, increases SA node firing and AV conduction |
| Timing | Remove atropine from cardiac arrest algorithm (2020 AHA guidelines); still used for bradycardia management |
| NCLEX Focus | Atropine NOT used in cardiac arrest (asystole/PEA). Used for SYMPTOMATIC BRADYCARDIA pre-arrest. |
Calcium Gluconate / Calcium Chloride
1g IV (calcium gluconate) or 500 mg–1g (calcium chloride)
| Indication | Hyperkalemic arrest, hypocalcemia, calcium channel blocker or beta-blocker toxicity |
| Mechanism | Stabilizes cardiac membranes against effects of hyperkalemia; provides calcium for contractility |
| Timing | For hyperkalemic or calcium channel blocker arrest — not routine |
| NCLEX Focus | Calcium gluconate: hyperkalemia cardiac membrane stabilization. First step in hyperkalemic arrest BEFORE insulin/bicarb. |
Hs and Ts — Reversible Causes of Cardiac Arrest
| Cause | Intervention | |
|---|---|---|
| H | Hypovolemia | IV fluid bolus |
| H | Hypoxia | Oxygenation, ventilation, advanced airway |
| H | Hydrogen ion (acidosis) | Bicarbonate, ventilation to normalize CO₂ |
| H | Hypo/Hyperkalemia | Calcium gluconate (hyperkalemia); potassium replacement (hypokalemia) |
| H | Hypothermia | Warming — continue CPR until rewarmed to 30–35°C |
| T | Tension pneumothorax | Needle decompression (2nd ICS, MCL) then chest tube |
| T | Tamponade (cardiac) | Pericardiocentesis |
| T | Toxins | Specific antidote per toxin (naloxone for opioid; sodium bicarb for TCA) |
| T | Thrombosis (pulmonary) | Thrombolytics during CPR if PE suspected; mechanical thrombectomy |
| T | Thrombosis (coronary) | Emergent coronary angiography/PCI post-ROSC |
Hs and Ts are especially important in PEA and asystole — these rhythms often have a reversible cause. Search actively and treat simultaneously with CPR.
Post-ROSC (Return of Spontaneous Circulation) Care
| Parameter | Target / Action |
|---|---|
| Blood pressure | MAP ≥ 65–70 mmHg (avoid hypotension); systolic BP ≥ 90 mmHg. Use vasopressors (norepinephrine) if needed. |
| Oxygen | SpO₂ 94–99% — titrate O₂ to AVOID hyperoxia (FiO₂ 1.0 immediately post-ROSC is harmful — causes oxidative injury to reperfused brain). Also avoid hypoxia. |
| Ventilation | ETCO₂ 35–45 mmHg (normocapnia). Avoid hyperventilation (causes cerebral vasoconstriction) and hypoventilation. |
| Temperature (TTM) | Targeted Temperature Management: prevent fever (temperature ≥ 37.5°C actively treated); achieve and maintain 32–36°C for 24h in comatose post-cardiac arrest patients — reduces neurological injury from reperfusion. |
| Glucose | Maintain glucose 140–180 mg/dL. Avoid hypoglycemia and hyperglycemia post-arrest. Monitor frequently. |
| Coronary catheterization | Emergent coronary angiography for STEMI or suspected coronary cause (even without ST elevation in some patients). ROSC + STEMI = emergent PCI. |
| Neurological monitoring | Continuous EEG for seizure detection (clinical seizures may be absent — use EEG). Avoid sedation that masks seizures. GCS and neuro checks. CT head if indicated. |
NCLEX Pearls
Compression rate: 100–120/min. Faster or slower is less effective.
CPR immediately after each defibrillation — do not check pulse right after shocking. Resume for 2 minutes, THEN check rhythm.
Epinephrine q3–5 min for ALL rhythms. Amiodarone for REFRACTORY VF/pVT (after ≥ 3 shocks).
Atropine is NOT used in cardiac arrest (2020 AHA guidelines removed it from arrest algorithms). Used only for symptomatic bradycardia.
PEA and asystole = search Hs and Ts aggressively. These rhythms often have a treatable cause.
Post-ROSC: avoid hyperoxia — titrate O₂ to SpO₂ 94–99%. Avoid hyperventilation — target ETCO₂ 35–45.
Sudden PETCO₂ rise during CPR = ROSC — check for pulse without stopping compressions first.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with Emergency Nurses Association (ENA) · AHA ACLS / PALS Guidelines · Advanced Trauma Life Support (ATLS). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →