ACLS Updates

Andy Little, DO and Cameron Berg, MD

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The summary below is from an episode of ERcast: Clinical Perspectives

Cardiac arrest care has shifted toward fewer, higher-yield interventions: prioritize high-quality CPR, use waveform capnography to guide ventilation, and avoid reflex early intubation. The 2020 ACLS updates also narrow vasopressor strategy to epinephrine and define where intra-arrest VA ECMO may fit.

2020 ACLS Cardiac Arrest Pearls

Capnography over reflex intubation: Waveform EtCO2 is the preferred bedside tool to monitor ventilation during resuscitation, and unless airway obstruction caused the arrest, immediate endotracheal intubation is usually not the priority.
Fast familiar airway choice: Advanced airways have not shown better clinical outcomes in arrest, so the best device is often the one your team can place quickly without interrupting compressions, a nuance we get into in the episode.
Single vasopressor strategy: Epinephrine remains the go-to vasopressor; piling on multiple pressors adds complexity without improving favorable neurologic outcomes after cardiac arrest.
Coronary perfusion target: The physiologic rationale for vasopressors is coronary perfusion, with diastolic blood pressure above 35 mmHg as the named goal linked to better chances of ROSC.
Prehospital care matters most: Cardiac arrest outcomes are tied closely to early bystander and EMS actions, and hands-only CPR remains one of the strongest evidence-based links in the Chain of Survival.
Naloxone in BLS guidance: The updated guidelines explicitly mention naloxone at the BLS level, reflecting opioid-associated arrest care while keeping compressions and basic resuscitation fundamentals front and center.

ECLS and Post-Arrest Priorities

Selective intra-arrest VA ECMO: ECLS in adult arrest means VA ECMO, not VV ECMO, and it is not routine care; the strongest signal is in carefully selected refractory VF or pulseless VT.
Time-sensitive cannulation window: ECLS success falls off quickly with delay, with cannulation ideally occurring within 15 minutes of arrest. We walk through the systems implications in the chapter.
Protocolized team response: Intra-arrest ECMO is a full-system intervention, not a solo procedure, so programs need a clear activation pathway, role assignment, and candidate selection process.
Temperature management emphasis: After ROSC, avoiding hyperthermia appears more important than chasing a specific low target temperature, shifting post-arrest care toward disciplined temperature control.
Immediate cath for STEMI: Post-arrest patients with STEMI still need urgent coronary angiography, a high-stakes step that should not be missed once circulation is restored.

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References:

Panchal AR, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S366-S468. PMID: 33081529
Jabre P, et al. Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial. JAMA. 2018;319(8):779-787. PMID: 29486039
Holmberg MJ, et al. Vasopressors during adult cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2019;139:106-121. PMID: 3098087

Faculty

Andy Little, DO
Dr. Andy Little is an emergency medicine physician and educator. He earned his medical degree from the Ohio University Heritage College of Osteopathic Medicine and completed his emergency medicine residency at OhioHealth Doctors Hospital Emergency Medicine Residency, where he served as Chief Resident. He has received multiple national awards, including recognition from the American Osteopathic Association, American College of Osteopathic Emergency Physicians, and Emergency Medicine Residents' Association.
Cameron Berg, MD
Based in Minneapolis, MN, Dr. Berg focuses on simplifying complex patient care processes, such as chest pain, syncope, and heart failure treatment. Since 2020, he has also been navigating his own recovery from a TBI after a bicycle accident. When he isn't in the clinic, Cameron is usually busy keeping his three young children alive and happy.