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Advance Cardiovascular Life Support and Mega Code Protocol

Mark Joseph S. Tunac, RN

Changes in 2010 Update


In basic life support, compression depth has been increased to between 5 & 6 cm.

Previous studies on both suggested that to achieve ROSC, CPP of over 15 mmHg during chest compressions are required and that the depth previously recommended of 45 cm for chest compressions was inadequate.

Minimizing of disruption in the compression sequence

Defibrillation should take a maximum period of five seconds, with charging during chest compressions.

For tracheal intubation, ten seconds hands-off time for the passage of the tube is the only point at which compressions are paused.

Pulse checks are only undertaken where there are signs suggestive of ROSC.


The use and timing of drugs have been simplified.

Atropine, long given for asystole and slow PEA, is discontinued, it remains for peri-arrest management. The tracheal route of drug administration is not recommended except in neonates following the widespread introduction of intraosseous devices.


2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Management of Cardiac Arrest

Cardiac arrest can be caused by 4 rhythms: ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electric activity (PEA), and asystole.

VF represents disorganized electric activity, whereas pulseless VT represents organized electric activity of the ventricular myocardium. Neither generates significant forward blood flow. PEA encompasses a heterogeneous group of organized electric rhythms associated with either absence of mechanical ventricular activity or mechanical ventricular activity that is insufficient to generate a clinically detectable pulse.
Asystole ( ventricular asystole ) represents absence of detectable ventricular electric activity with or without atrial electric activity.

For VF/pulseless VT, attempted defibrillation within minutes of collapse. For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.

Other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge.
Combination of higher quality CPR and post arrest interventions such as therapeutic hypothermia and early percutaneous coronary intervention (PCI), doesnt necessarily improves the outcome. Periodic pauses in CPR should be as brief as possible and only as necessary to assess rhythm, shock VF/VT, perform a pulse check when an organized rhythm is detected, or place an advanced airway.

Monitoring and optimizing quality of CPR is encouraged and includes:

Optimizing chest compression rate and depth, adequacy of relaxation, and minimization of pauses. Monitoring partial pressure of end-tidal CO2 [PETCO2], arterial pressure during the relaxation phase of chest compressions, or [ScvO2] when feasible.

In the absence of an advanced airway, a synchronized compression ventilation ratio of 30:2 is recommended at a compression rate of at least 100 per minute. After placement of an advanced airway, the provider performing chest compressions should deliver at least 100 compressions per minute without pauses for ventilation.

The provider delivering ventilations should give 1 breath every 6 to 8 seconds (8 to 10 breaths per minute) and should avoid delivering an excessive number of ventilations.


Megacode Protocol

Members of the Code Team

Team Leader Chest Compressor Airway Manager IV therapist Electrical Therapist Code Recorder

Elements of Effective Code Team

Closed loop Communication Clear Messages Clear roles and responsibilities Know ones limitation Knowledge sharing Constructive Intervention Re-evaluation and summarizing Mutual Respect

V tach / V Fib (-) Pulse





V tach (+) Pulse

Check BP Stable (BP> 90/60) Unstable (BP< 90/60)



100 joules

A Fib/SVT/A flutter

Check pulse and BP Stable (BP> 90/60) Unstable (BP< 90/60)

Vagal stimulation

MEDS SVT 50-100 joules A fib 120-200 joules



Check electrode and Pulse (-)




S Tach/ NSR

Check BP and Pulse Stable (BP> 90/60) Unstable (BP< 90/60)

Fast drip of Saline solution or
Dopamine Drip

S Brady

Check BP and Pulse Stable (BP> 90/60) Unstable (BP< 90/60)


Post Cardiac Care (PCC)


Check O2 saturation

SpO2 70- 92
BVM OPA/NPA Non-Rebreather Mask at 10-15LPM

SpO2 <70
ET LMA Combitube


Insert NGT Insert IFC 12 lead or 14 lead ECG X-ray ABG and other blood works Transfer to ICU