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Shockable rhythms Epidemiology

Occur in 25% of cardiac arrests
Occur in 25% of non-shockable rhythms


Shockable rhythms treatment

1) Confirm the arrest
2) Call the resus team
3) Uninterrupted chest compressions whilst applying defib pads (below right clavicle and at V6 midaxillary position)
4) Tell team next actions (........)
5) Rhythm analysis, STOP COMPRESSIONS and confirm VF from ECG
6) Resume compressions immediately
6a) Team member selects 150-200J biphasic for first shock, 150-360J subsequent shocks) PRESS CHARGE
6b) While charge get everyone clear except for person performing compressions
6c) Once charge compression member stands clear, then GIVE SHOCK
6d) Restart 30:2 compressions. Continue for 2mins
7) Prepare team for next pause
8) Check rhythm STOP compressions

If still VF/VT continue repeat the above cycle and give second shock.

After second shock give a third shock. Resume compressions and give 1mg IV adrenaline and 300mg IV amiodarone without stopping compressions.

Repeat and give IV adrenaline only for alternate shocks.

A further 150mg of amiodarone can be given if VT/VF persists


Evidence of ROSC

Check carotid pulse
End tidal CO2
Start post resus care

If none continue CPR and switch to non-shockable algorithm

If asystole occurs then switch to non-shockable rhythms


Alternative to amiodarone?

Lidocarine 1mg/kg


Precordial thump

Only appropriate in a monitored, witnessed arrest with many clinicians and defib not readily available.

Low success rate in shockable rhythms and only if given in the first few seconds of onset

More successful in pulseless VT than VF.


VT or VF in the cath lab

Confirm arrest and call for help

3 successive shocks (Count as 1 ALS shock)

Start chest compressions for 2 mins as normal


Non-shockable rhythms

Start CPR 30:2-prepare Airway and IV access

Give adrenaline 1mg IV as soon as IV access is gained

Gain secure airway then continue compressions without pause

Recheck the rhythm after 2 mins

If organised electrical activity start post resus care

If no pulse: continue CPR
Recheck rhythm after 2mins
Give 1mg adrenaline every alternate CPR compression



Bag mask
Preferably supraglottic device used e.g. i-gel
laryngeal mask

Once inserted ventilation 10 per minute



Observe patient for 5mins before confirming death:
- Absent central pulse
- Absent heart sounds
- Asystole on ECG
- Absent contractile activity on ECHO

After 5mins check corneal/light reflexes before announcing time of death.



Reduction of the pre and post shock pause can influence the likelihood of success, because interruptions longer than 5 seconds reduce the chance of a shock restoring a spontaneous circulation. If it was considered appropriate to start resuscitation, it is usually worthwhile continuing whilst VF persists.

Pulse checks should be performed only when organised electrical activity compatible with a pulse is seen. Once given, adrenaline should be repeated every 3-5 minutes, irrespective of cardiac arrest rhythm.

In primary VF/VT, adrenaline is withheld until after the third shock. If ROSC occurs before the third shock, no adrenaline will have been given. If IV access cannot be achieved within 2 minutes of resuscitation, then intraosseous access should be considered. The initial dose of amiodarone is 300mg IV.



When considering the treatment of PEA/Asystole, give 1mg adrenaline as soon as vascular access is achieved. There is no evidence that the routine use of atropine is effective in the treatment of asystole or PEA.

Quick and effective treatment of an identified reversible cause will increase the likelihood of ROSC. However, external pacing may be effective for p-wave asystole, but is unlikely to be effective in true asystole.