Cardiac Surgery Arrest - CALS Protocol (STS/EACTS)

Algorithm Steps

1. ▶

   Start

   CARDIAC ARREST Post-Cardiac Surgery

   Patient within 10 days of median sternotomy for cardiac surgery

   1. ◆

      Decision

      Identify Rhythm

      Check monitor immediately

      • VF/pVT: Shockable
      • Asystole: Pace if wires present
      • PEA: Start ECC immediately
      1. ●

         Action

         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)
         1. ●

            Action

            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)
            1. ●

               Action

               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
               1. ◆

                  Decision

                  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
                  1. ●

                     Action

                     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
                     1. ●

                        Action

                        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
                        1. ✓

                           Outcome

                           ROSC Achieved

                           Post-resuscitation care

                           • Identify and treat underlying cause
                           • Consider return to OR if surgical issue
                           • Optimize hemodynamics
                           • Neurologic assessment
                  2. ●

                     Action

                     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
      2. ●

         Action

         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
      3. ●

         Action

         PEA

         Start ECC immediately

         • BEGIN EXTERNAL CHEST COMPRESSIONS
         • Standard rate 100-120/min
         • Consider reversible causes
         • PEA often = tamponade or hypovolemia
   2. ⚠

      Warning

      ⚠️ DO NOT Give 1mg Epinephrine

      Standard ACLS dose can damage fresh grafts and cause severe post-ROSC hypertension