ACLS for Cardiac Arrest in OR

ACLS for Cardiac Arrest in the Operating Room

Cardiac arrest in the community is a fairly common problem for which rescusitation guidelines have been studied and developed. Cardiac arrest in the peri-operative setting is relatively rare,1 and for numerous reasons, knowing when to initiate CPR can be difficult.2 False alarms in the operating room occur regularly and outnumber real events. Common reasons for the alarms are equipment failures, such as sensor disconnections, and electrocautery interference with EKG. Patient co-morbidities, such as morbid obesity, vasculopathy, and hypothermia can also make certain monitoring more difficult in the operating room.2 Also, bradycardia and hypotension are relatively common in the operating room, especially under general anesthesia. The majority of these patients recover to adequate hemodynamics with minimal intervention needed.

Signs of Cardiac arrest in the OR2

  1. EKG with pulseless rhythm
    • Ventricular Tachycardia [V-Tach]
    • Ventricular Fibrillation [V-Fib]
    • Severe Bradycardia
    • Asystole
  2. Loss of Carotid pulse > 10 seconds
  3. Loss of End Tidal CO2 on capnograph
  4. Loss of Arterial line tracing
  5. Loss of waveform on pulse oximeter
  • Note: There are numerous reasons for false alarms/false positives suggesting cardiac arrest. Once cardiac arrest is confirmed, effective CPR should be administered immediately.

Features of Adequate CPR2

Effective chest compressions are indicated by different monitors used commonly in the OR setting, and are associated with higher rates of successful return of spontaneous circulation (ROSC)

  • End Tidal CO2 > 20mm Hg on capnography (An ETCO2 <10mm Hg after 20 min of standard ACLS is associated with 100% failure of ROSC)
  • Diastolic pressure of 30-40mm Hg by arterial line catheter at time of full compressions
  • Coronary perfusion pressure (CPP) > 15 mmHg. (Diastolic BP- CVP)

Corrective measures for clinical progression to shock/cardiac arrest2

  • Recognize a true crisis
  • Call for help and a defibrillator
  • Hold surgery and anesthetic if possible
  • Adjust FiO2 to 1.0
  • Confirm airway positioning
  • Assess breathing circuit integrity

Generate a Differential Diagnosis

  • Consult with surgical staff and assess procedure
  • Review recent medications administered
  • Consider tension pneumothorax if airway resistance high, consider CXR or point of care ultrasound
  • Obtain ECHO if reasonable to assess heart function
  • Empiric corticosteroid replacement with hydrocortisone 50mg iv and fludrocortisones 50ug PO/NG (in patients not previously on steroids)

Perioperative Cardiac Arrest

  • Circulation
    • Pulse check > 10 sec
    • Effective 2 rescuer CPR:
      • Minimize interruptions
      • Compression rate 100 compressions/min
      • Depth 2 inches, full decompression
      • Adjust CPR for DBP (a-line) >40 mmHg, ETCO2 >20 mmHg
    • Administer drugs
    • Attempt CVL placement
  • Airway
    • Bag mask ventilation until intubated
    • Endotracheal intubation
  • Breathing
    • Respiratory rate 10 breaths/min
    • Obtain visible chest rise
  • Defibrillation if shockable rhythm (VFIB, pulseless VTACH)
    • Repeat defibrillation every 2 min if shockable rhythm.

Post Cardiac Arrest

  • Invasive monitoring
  • Final surgical plan, transport to ICU
  • Consider therapeutic hypothermia

Management of Cardiac Arrest in OR 2,3

Once a true cardiac arrest has been established and help has been called, CPR should be established immediately. Treatment will then depend on the rhythm seen by EKG monitoring.


Pulseless Rhythms

Shockable Rhythms


  1. CPR until defibrillator attached
  2. Give 1 shock 200-360 J Biphasic
  3. Resume CPR immediately
  4. If VTACH- give 1g CaCl iv
  5. Check capnometer for CO2, if present hold CPR and check rhythm
  6. If still in VFIB/VTACH, continue CPR and repeat steps 2-3. (See Asystole/PEA if not shockable)
  7. Give Epinephrine 1mg IV, repeat q 3-5 min (may replace 1 dose of Epi with Vaso 40U iv)
  8. Check Rhythm after 5 cycles (30:2) CPR or 2 minutes of continous compressions (100/min)
  9. If a shockable rhythm, repeat steps 2-3.
  10. Consider anti-arryhthmics
  11. Amiodarone 300mg IV or
  12. Lidocaine 1-1.5mg/kg IV q 3-5 min x 3.
  13. Consider Magnesium sulfate 2g IV for ? Torsades de pointes
  14. If pulse present, begin post-resuscitation care.

Not Shockable


  1. Continue CPR
  2. Epinephrine 1mg IV, repeat q3-5 min (may replace 1 Epi dose with 40U Vaso IV)
  3. Continue CPR (30:2 non-intubated) x 5 cycles (if intubated continuous compressions x 2min @ 100/min with 6-8 breaths/min)
  4. Consider CaCl 1g if hyperkalemia in differential
  5. If PEA, consider:
  • Hypovolemia
  • Tamponade
  • Tension pneumothorax
  • Auto-PEEP
  • Embolism
  • Check rhythm/pulse; If Asystole/PEA, repeat steps 1-3. If shockable, see VFIB/VTACH.
  • If pulse present, begin post-resuscitation care.


1. Gabrielli, A et al. Anesthesia Advanced Circulatory Life Support. Monograph, ASA Committee on Critical Care Med. 2008 Feb. Pages1-45.

2. Moitra, V et al. Anesthesia Advanced Circulatory Life Support. Can J Anesth/J Can Anesth (2012) 59:586-603.

3. McEvoy, et al. 4-Step Approach to ACLS Management, pocket reference card. Medcial Univerisity of South Carolina, 2011.