CARDIAC ARREST Post-Cardiac Surgery
Patient within 10 days of median sternotomy for cardiac surgery
All Pathways
Cardiothoracic SurgeryEmergency
Cardiac Surgery Arrest - CALS Protocol (STS/EACTS)
Cardiac Surgery Arrest - CALS Protocol (STS/EACTS): CARDIAC ARREST Post-Cardiac Surgery → Identify Rhythm → VF or Pulseless VT → Consider Reversible Cau...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Decision Identify Rhythm
Check monitor immediately
- VF/pVT: Shockable
- Asystole: Pace if wires present
- PEA: Start ECC immediately
03Action VF or Pulseless VT
May delay ECC up to 1 minute for defibrillation
- 3 sequential shocks (within 1 minute)
- 150-200J biphasic or 360J monophasic
- If unsuccessful after 3 shocks → Start ECC
- DELAY in ECC up to 1 min permitted (graft protection)
04Action Consider Reversible Causes
Rapid assessment during resuscitation
- TAMPONADE (most common) - sudden drop in drainage
- Hypovolemia/Hemorrhage
- Hypoxia - check ETT, ventilator
- Tension pneumothorax
- Electrolyte abnormality (K+, Ca2+, Mg2+)
- Graft occlusion/MI
- Drug error (verify infusions)
05Action LOW-DOSE Epinephrine
NOT standard 1mg ACLS dose
- Use 50-300 mcg IV (0.05-0.3mg)
- Standard 1mg may cause graft damage
- May cause severe hypertension post-ROSC
- Repeat every 3-5 min if needed
06Decision Resternotomy Indicated?
Consider within 5 minutes if no ROSC
- INDICATIONS for immediate resternotomy:
- • No ROSC after above measures
- • VF refractory to 3+ shocks
- • Suspected tamponade or hemorrhage
- • Within first 10 days post-op
07Action EMERGENCY RESTERNOTOMY
Within 5 minutes of arrest if possible
- Can be performed at bedside in ICU
- Sterile field not essential - save life first
- 5-item kit: scalpel, wire cutter, needle holder, retractor, sucker
- Cut wires, open sternum, evacuate clot
- INTERNAL cardiac massage: 100-120/min
- Produces better cardiac output than external CPR
08Action Internal Cardiac Massage
Superior to external compressions
- Two-handed technique preferred
- 100-120 compressions/min
- Can achieve 2-3x better coronary perfusion
- Direct visualization of heart
- Can identify/treat tamponade, hemorrhage
09Outcome ROSC Achieved
Post-resuscitation care
- Identify and treat underlying cause
- Consider return to OR if surgical issue
- Optimize hemodynamics
- Neurologic assessment
10Action Continue Modified ACLS
If ROSC not achieved and resternotomy not feasible
- Continue ECC
- Consider amiodarone 150-300mg for refractory VF
- Correct electrolytes
- Optimize ventilation
- Reassess every 2-minute cycle
- Path rejoins step 09Shared downstream outcome
- Path rejoins step 06Shared downstream outcome
11Action Asystole / Severe Bradycardia
Attempt pacing if epicardial wires present
- Pace via epicardial wires if available
- VVI mode, max output
- If no capture → Start ECC
- Consider atropine 0.5-1mg if time permits
- Path rejoins step 04Shared downstream outcome
12Action PEA
Start ECC immediately
- BEGIN EXTERNAL CHEST COMPRESSIONS
- Standard rate 100-120/min
- Consider reversible causes
- PEA often = tamponade or hypovolemia
- Path rejoins step 04Shared downstream outcome
13Warning ⚠️ DO NOT Give 1mg Epinephrine
Standard ACLS dose can damage fresh grafts and cause severe post-ROSC hypertension
Guideline Source
STS Expert Consensus for Resuscitation of Patients Who Arrest After Cardiac Surgery
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Requires trained ICU/cardiac surgery team
- Emergency resternotomy kit must be immediately available
- Standard ACLS drugs NOT recommended at full dose
- Does not apply to thoracic-only surgery patients
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Cardiac Surgery Arrest - CALS Protocol (STS/EACTS)?
The Cardiac Surgery Arrest - CALS Protocol (STS/EACTS) is a emergency clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on STS Expert Consensus for Resuscitation of Patients Who Arrest After Cardiac Surgery.
What guideline is the Cardiac Surgery Arrest - CALS Protocol (STS/EACTS) based on?
This algorithm is based on STS Expert Consensus for Resuscitation of Patients Who Arrest After Cardiac Surgery (DOI: 10.1016/j.athoracsur.2016.10.033).
What are the limitations of the Cardiac Surgery Arrest - CALS Protocol (STS/EACTS)?
Known limitations include: Requires trained ICU/cardiac surgery team; Emergency resternotomy kit must be immediately available; Standard ACLS drugs NOT recommended at full dose; Does not apply to thoracic-only surgery patients. Individual patient factors may require deviation from these recommendations.
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