Beyond ACLS: CPR, Defibrillation, and Epinephrine

Advanced Cardiac Life Support (ACLS) provides a well structured framework for those who resuscitate infrequently. There is room to move beyond the algorithm to potentially provide better care for our patients for those who resuscitate frequently. I will describe some tweaks to the way CPR, defibrillation, and medications are delivered in the arrests I manage.

Cardiopulmonary Resuscitation (CPR)

  • Team: Performing a successful resuscitation is a team sport. Having a ‘pre-arrival code briefing’ will help to get everyone in the game, and can help to reinforce the goal of high quality, minimally interrupted CPR.
  • Quality of CPR: Reinforcing to the ED technicians / students / nurses  who will be delivering CPR that they are the most important member of the team helps. I try to have each new compressor match the best end-tidal CO2 that was achieved by the person they are replacing. If the end-tidal starts to fall, I will trade them out early.
  • Interruptions: The ‘pre-arrival code briefing’ also reinforces the need for minimally interrupted CPR. This involves counting out loud during cardiac ultrasound assessments, skipping pulse checks in favor of watching for a bump in the endtidal CO2, and reminding participants that compressions DO NOT need to be stopped during attempts at airway management.

CPR Interruptions


To minimize the interruption in compressions during defibrillation I will have the provider delivering compressions be the one in charge of calling the shock. Once a shockable rhythm has been identified, compressions will continue while the defibrillator is charging. The compressor will then ‘call the shock’ and say shock in 3, 2, 1, and will lift their hands off the chest for <2 seconds, and then immediately resume compressions and follow the ETCO2 data for evidence of ROSC. This technique requires a pre-resuscitation team briefing. The benefit of this technique is that it involves the ED technicians / nurses / students in the resuscitation and allows them to take an active role in the arrest (rather than being just a human CPR machine), it also allows for a very brief perishock pause.

Drug Dosing

ACLS recommendations: ‘consider epi, 1mg every 3-5 minutes’ allow for some wiggle room in the way we choose to deliver intra-arrest vasopressors.

It can cause undue unrest in your team if you skip the epi entirely without a very lengthy explanation. Epinephrine in cardiac arrest was already covered on REBEL EM (Is It Time to Abandon Epinephrine in Out-Of-Hospital Cardiac Arrest?). I will often  hang an epi drip at 0.5 mcg/kg/min instead of having team members distracted by giving epi every 3-5 minutes. For a 100kg patient this will deliver 50 mcg per minute, or 250 mcg every 5 minutes. This dosing level equates to about 25% of ‘code dose’ epi, and should help to support intra-arrest diastolic coronary perfusion without hammering the heart and brain as hard as code dose epi does. This dosing approach treads the middle ground between the group who feel there is no benefit to epi during cardiac arrest, and those that are dosing their epi based on diastolic pressures to enhance coronary artery perfusion.

In the CHEER trial [1], once the decision to initiate E-CPR was made an epi drip was started at 50 mcg/min.(this is the same as 0.5 mcg/kg/min for a 100kg patient) For a full description of their protocol see the link from the ED-ECMO website: ED ECMO from the Alfred

The benefits to the drip are two-fold:

  • Cognitive offloading: With the epi drip running, the team member who was having to remember epi every 3-5 minutes can now focus on other aspects of the code (ie, good, minimally interrupted compressions).
  • Avoidance of post ROSC drop in BP: With conventional code dose epi administration a big drop in post Return of Spontaneous Circulation Blood Pressure (ROSC BP) can be seen once the epi wears off in patients who will have post ROSC pressor dependent hypotension. With an epi drip already running this post ROSC drop in BP can be averted, or can be identified, and treated more easily. Having an epi drip running also makes managing post ROSC MAP goals easier to achieve.

Running the epi drip is especially useful in those situations where compressions are anticipated to be needed for >15 minutes, i.e. intra arrest lytics for suspected or confirmed massive PE where 2 doses of lytics are given 15 min apart, or during the cannulation phase for E-CPR.

Spend an extra 10 minutes in the room post ROSC


A great piece of advice that was given by Sara Gray (@EmICUcanada) in her talk at SMACC Chicago  is to spend an extra ten minutes at the bedside sweating the small stuff after an intubation, or after achieving ROSC.

Optimize Post Arrest Care

  • Turn down the FiO2 to avoid hyperoxia (Pa02 >300mmHg)  There is a mortality association between elevated post arrest PaO2 and death [2].  Kilgannon et. al. found that every 100mmHg elevation in peak post ROSC Pa02 was associated with a 24% increase in mortality [3].
  • Tweak the vent (6cc/kg tidal volume)
  • Check cuff pressure on ETT tube [4]
  • Optimize temperature: 36 degrees by 4h post ROSC, or sooner if possible
  • Optimize Mean Arterial Pressure (MAP)
  • Optimize position (head of bed elevation to 30 degrees) [5]
  • Confirm cause of arrest (if possible) Make sure that STEMI isn’t a PE, make sure that PE isn’t a STEMI, and ALWAYS consider dissection.
  • TEACH: Check with your team if any of the interventions need clarification or explanation. If you are convincing, they will do this for other patients also.

Take Home Points

  • Brief your team before patient arrival: CPR quality (ETCO2), limit all pauses, and smarter Defibrillation
  • Consider an epi drip instead of code dose epi pushes: 0.5 mcg/kg/min IV/IO
  • Sweat the small stuff after you get ROSC. 10 min is a small investment for improved patient outcomes

I am far from an expert resuscitationist, but these simple interventions have allowed for a calmer, quieter room during cardiac arrest resuscitations, and a realization that I am providing the best care possible for my patients.


  1. Stub D et al. Refractory Cardiac Arrest Treated with Mechanical CPR, Hypothermia, ECMO and Early Reperfusion (The CHEER Trial). Resuscitation 2015. PMID: 25281189
  2. Wang CH et al. The Effect of Hyperoxia on Survival Following Adult Cardiac Arrest: A Systematic Review and Meta-Analysis of Observational Studies. Resuscitation 2014. PMID: 24892265
  3. Kilgannon JH et al. Relationship Between Supranormal Oxygen Tension and Outcome After Resuscitation from Cardiac Arrest.  Circulation 2011. PMID: 21606393
  4. Hoffman RJ et al. Experienced Emergency Medicine Physicians Cannot Safely Inflate or Estimate Endotracheal Tube Cuff Pressure Using Standard Techniques. Am J Emerg Med 2006. PMID: 16490640
  5. Grap MJ et al. Ventilator-Associated Pneumonia: The Potential Critical Role of Emergency Medicine in Prevention. J Emerg Med 2012. PMID: 20692786

Also Checkout:

Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)

Cite this article as: Rob Bryant, "Beyond ACLS: CPR, Defibrillation, and Epinephrine", REBEL EM blog, July 23, 2015. Available at:
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Rob Bryant

Adjunct Assistant Clinical Professor of Emergency Medicine at Utah Emergency Physicians
REBEL EM Guest Contributor and Author

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10 thoughts on “Beyond ACLS: CPR, Defibrillation, and Epinephrine”

  1. In the last hospital that I worked for, in 2008, CO2 Monitoring was integrated in all ICUs and ER monitors…that is SICU, MICU, AND PICU…..I retired in 2012 and the MDs never used the function…RTs like me Installed the monitoring lines to the vent circuits to entertain ourselves and impress the opposite sex, RNs or MDs….I knew CO2 monitoring since 1996 when it was an option offered in a home care company I worked for, that also did sleep studies. The Doctors just did not care to bother with it….. ( !!!! ) That hospital was not in a small city or town out of the way….It was in Brooklyn, New York City and I worked there for 14 years

    • Hello Manueal,
      EtCO2 monitoring is an underutilized tool in the code situation, and I have personally seen it reduce CPR pause times. Sounds like you have been way ahead of the curve in terms of knowledge translation.


  2. Good stuff Rob.
    Also consider an easy way of monitoring BP in the arrest phase–use a doppler over the antecubital fossa to detect blood flow during CPR, and inflate a manual cuff on that arm to determine the MAP. This will guid you in vasopressin and levophed treatment—get that coronary blood flow up by increasing aortic root pressure for MAP > 80 mm Hg.

  3. Thanks Jim,
    Great pearl re: AC fossa doppler for assessment of MAP, I have not tried this. Most of my time is spent focusing on minimizing the interruptions to compressions, but this is a great tip for those codes where prolonged CPR may be necessary.

  4. Thank you for sharing. I’m just starting my EMT career and starting paramedic this fall. love learning about better treatment in the field and how to better patient outcome. Great job, loved the read!

  5. Do you have any outcomes for the epi infusion vs 1mg every 3-5? Preferably neurologically intact outcomes with the epi drip vs epi push?
    I am doing research on this in attempt to get a clinical trial started at my service. Thank you in advance.

  6. When you are giving 50mcg/min of epi, that would be equivalent to 50ml/min- decent amount of fluid. Are you still using the 1mcg/ml concentration epi drip or making a more concentrated solution? Are you running that in on a pump or just hanging it and estimating? Do you push antiarrythmics through the epi line if you only have one IV?

    • Hey Jeb,
      The 50mcg/min of epi is for the initial resuscitation (i.e. IV fluids and epi at the same time). After the initial liter a more concentrated solution will need to be made. The “dirty” epi drip is a free flow (the is why it’s dirty). The epi titrated drip is on a pump where rate can be controlled better. I have never had the issue of just one IV, because I place bilateral IOs in these patients. Hope this helps.



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