ICU Basics

Cardiac arrest and ACLS

Arrest After Cardiac Surgery Algorithm

Shock or pace first, reopen the chest within 5 minutes

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Call the arrest and the resternotomy team

  • Confirm on the monitor: VF or VT, asystole, or a rhythm with a flat arterial trace and EtCO₂ (PEA)
  • Call the cardiac surgeon and the resternotomy team (gown up now), anesthesia, perfusion and the ICU lead
  • Manual defibrillator and the emergency resternotomy set to the bedside; no AED, no mechanical CPR device
  • Airway: FiO₂ 100%, PEEP off; check the tube, bag by hand, decompress a suspected tension pneumothorax

VF or pulseless VT → step 2Asystole or extreme bradycardia → step 3PEA → step 4

2 VF or pulseless VT: three quick shocks

  • Up to 3 shocks in quick succession within 1 minute, before compressions (usual biphasic energy, 120–200 J)
  • Check the rhythm and arterial trace after each shock; no compressions between them
  • Still VF after the third: compressions, amiodarone 300 mg IV (or lidocaine 1–1.5 mg/kg), then a shock every 2 minutes
  • Prepare to reopen the chest now

ROSC → step 5Still VF or VT after 3 shocks → step 6Now asystole or extreme bradycardia → step 3Now PEA → step 4

3 Asystole or extreme bradycardia: pace now

  • Already paced: pause it for a moment to exclude VF hidden under the spikes
  • Epicardial wires: DDD 80–100/min at maximum atrial and ventricular output, or the emergency (DOO) key
  • Confirm capture on the arterial trace, not just by pacing spikes
  • No wires, or no output within 1 minute: start compressions; no routine atropine

Capture with arterial pressure → step 5No capture or no output → step 6

4 PEA: pause the pacer and look for VF

  • Paced rhythm with a flat arterial trace: pause pacing briefly to unmask VF
  • True PEA: start compressions; tamponade, bleeding or tension pneumothorax is the usual cause
  • Prepare to reopen; bedside echo only if it does not delay the resternotomy

VF underneath → step 2True PEA or asystole → step 6

5 After ROSC

  • MAP about 65–90; avoid surges that strain suture lines; restart infusions one at a time
  • Treat the cause: OR or chest exploration for bleeding or tamponade; 12-lead and echo for graft or valve failure
  • K⁺ 4.0–5.0 mEq/L, Mg²⁺ over 2.0 mg/dL, normal ionized Ca; recheck pacing thresholds
  • Post-arrest care: SpO₂ 90–98%, PaCO₂ 35–45, temperature control without fever, neuro checks

End of this path.

6 Compressions while the chest is prepared

  • External compressions to an arterial systolic over 60 mmHg; ventilate with 100% O₂
  • Stop infusions (sedation may continue); restart only what is needed after ROSC
  • No routine 1 mg epinephrine or vasopressin; small doses (0.05–0.1 mg) only if the senior clinician directs
  • Systolic under 60 despite good compressions: tamponade or bleeding until proven otherwise

Next: emergency resternotomy → step 7On IABP, Impella or VA-ECMO → step 8Review the reversible causes → step 9

7 Emergency resternotomy within 5 minutes

  • Up to day 10 after surgery: reopen within 5 minutes of the arrest; after that the senior clinician decides
  • Six roles: compressions, airway, defibrillator, team leader, drugs and infusions, ICU coordinator; plus the sterile team
  • Compress until the chest is open, then internal massage; internal paddles 20 J for VF
  • Minimally invasive surgery or delayed reopening: rapid ECMO in experienced centers

ROSC → step 5

8 On mechanical support

  • IABP: pressure trigger, 1:1, full augmentation during compressions; internal mode (about 100/min) only if CPR pauses with no cardiac activity
  • Impella: lower to P-2 during compressions; shock without touching the pump or console; echo for position after ROSC
  • VA-ECMO: if flow holds, the patient is still perfused; check the circuit, shock VF, compress only if flow fails; call perfusion
  • LVAD: assess perfusion before compressions (LVAD algorithm)

Next: emergency resternotomy → step 7

9 Reversible causes after cardiac surgery

  • Tamponade: drains suddenly stop, CVP and PA diastolic rise toward each other; reopening is the treatment
  • Bleeding: high drain output, falling Hgb; massive transfusion and reopen
  • Tension pneumothorax: high airway pressure, absent breath sounds, hypoxemia; decompress now
  • Also: graft occlusion or spasm, high or low K⁺, hypoxemia from the tube, hypovolemia, drug error

Back to compressions and resternotomy → step 7

Drugs in this algorithm

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