Give adrenaline as soon as possible, keep CPR going, and actively search for and treat the 4 Hs and 4 Ts, using POCUS only without interrupting compressions.
At the bedside
Timed steps- 1
Confirm PEA or asystole
0 minCheck leads, gain and pads; fine VF can look like asystole. Continue CPR.
- 2
Adrenaline 1 mg IV/IO
ASAPAs soon as access is available, then every 3-5 min.
- 3
Rhythm check
Every 2 minShockable → shock pathway. Organised rhythm → pulse check. Otherwise continue CPR.
- 4
Work through Hs and Ts
ThroughoutUse history, ABG/VBG (K+, pH, glucose, Hb), ETCO2 and POCUS during the pulse check, without prolonging pauses.
- 5
Treat the cause
TargetedHyperkalaemia: calcium + insulin-dextrose + bicarbonate; tension: needle/finger thoracostomy; tamponade: pericardiocentesis; PE: thrombolysis; hypovolaemia: fluids/blood; toxins: antidotes.
- 6
Continue CPR 60-90 min
If thrombolysedAfter fibrinolysis for PE, continue resuscitation for 60-90 min before stopping.
- 7
Decide on continuing
20+ minConsider cause, ETCO2 trend (persistently < 10 mmHg after 20 min of ALS in an intubated patient supports stopping as part of a multimodal decision), comorbidity, and wishes.
Hyperkalaemia, hypocalcaemia, CCB overdose arrest
Calcium gluconate 10% (or calcium chloride 10%)
- Dose
- Calcium gluconate 10% 30 mL (or calcium chloride 10% 10 mL)
Not routine in arrest; separate line from bicarbonate.
Hyperkalaemia or tricyclic overdose arrest
Sodium bicarbonate
- Dose
- 50 mmol
- Preparation
- ≈ 50 mL of 8.4% or ≈ 56 mL of 7.5%
PE-related arrest
Alteplase
- Dose
- 50 mg bolus; consider repeat 50 mg after 15 min
Continue CPR 60-90 min.
PE-related arrest (alternative)
Tenecteplase
- Dose
- Weight-based 30-50 mg (70-79 kg: 40 mg)
4 Hs and 4 Ts: clues and treatment
| Cause | Clues | Treat |
|---|---|---|
| Hypoxia | Respiratory arrest, blocked/displaced tube, low SpO2 before arrest | 100% O2, confirm tube with capnography, DOPE check |
| Hypovolaemia | Bleeding, GI loss, flat IVC, empty heart on POCUS | Rapid fluids/blood, stop bleeding |
| Hypo/hyperkalaemia and metabolic | CKD, missed dialysis, peaked T, wide QRS; DKA; hypocalcaemia | Calcium, insulin-dextrose, bicarbonate; dialysis |
| Hypothermia | Core temp < 30 °C, drowning | Rewarm; ECPR if available; withhold drugs < 30 °C (ERC) |
| Tension pneumothorax | Ventilated, trauma, line insertion, absent breath sounds, no lung sliding | Needle or finger thoracostomy, then drain |
| Tamponade | Post-cardiac surgery, trauma, malignancy, effusion with RV collapse on POCUS | Pericardiocentesis or resuscitative thoracotomy |
| Toxins | OP, aluminium phosphide, tricyclics, beta-blockers, calcium-channel blockers, local anaesthetics | Specific antidotes (atropine, bicarbonate, calcium, high-dose insulin, lipid emulsion) |
| Thrombosis (PE / coronary) | Dilated RV, DVT, chest pain, STEMI before arrest | Thrombolysis (PE), PCI (coronary), consider ECPR |
References
- 1
- 2
- 3
Non-shockable rhythm loop with reversible causes
Step 1 of ~6
CPR 2 min; IV/IO; adrenaline 1 mg ASAP then every 3-5 min
Based on Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; Soar J, Böttiger BW, Carli P, et al. Educational use; follow local protocol.
Evidence
- AHA 2025: adrenaline as soon as feasible in non-shockable rhythms. Routine calcium, bicarbonate and magnesium are not recommended. Pacing in established arrest is not recommended. POCUS for reversible causes "is not well established" and must not interrupt CPR. In intubated patients, ETCO2 ≤ 10 mmHg after 20 min of ALS may be one part of a multimodal decision to stop; never use ETCO2 alone in non-intubated patients.
- ERC 2025 Special Circumstances: detailed guidance on hyperkalaemia, hypothermia, PE, tamponade, toxins and other causes.
Controversies
- Bicarbonate in prolonged non-shockable arrest: observational signals but resuscitation-time bias; not recommended routinely.
- Termination of resuscitation rules are validated mainly in North American out-of-hospital settings, not in Indian in-hospital arrest.
🇮🇳 India notes
- Toxic causes are common in Indian ICUs: organophosphates, aluminium phosphide (celphos), yellow oleander, and snakebite with neuroparalysis (hypoxic arrest). See modules 28 and 29.
- Hyperkalaemia from missed dialysis and AKI is a frequent cause of PEA in Indian emergency departments.
References
- 1
- 2
- 3
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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.