โšก CPR CYCLE COMPLETE โ€” CHECK RHYTHM
ALS
Walkthrough
JRCALC 2026 ยท Adult Cardiac Arrest ยท Updated 15 Apr 2026
โš ๏ธ This tool supports clinical decision making. It does not replace clinical judgement. Always follow local protocols and seek senior advice when needed.
Was the arrest witnessed?
Witnessed
Collapse seen or monitored
Unwitnessed
Found in arrest
Special circumstances? (select all that apply)
๐Ÿฉธ Trauma
๐Ÿคฐ Pregnancy
๐ŸงŠ Hypothermia
๐ŸŒฌ๏ธ Asthma
๐Ÿ’Š Overdose / Toxin
โš–๏ธ Bariatric
Step 1 โ€” Confirm Arrest & Immediate Actions

Confirm Cardiac Arrest

Immediate Actions

What is the initial rhythm?
Shockable Rhythm โ€” VF / pVT

Shock 1 of sequence

โšก First shock โ‰ฅ150J biphasic โ€” escalate for subsequent shocks

Airway โ€” BEFR Order

1
B โ€” BVM
OPA/NPA adjunct. 30:2. Gentle 1-second breaths. Watch for chest rise.
2
E โ€” EtCOโ‚‚ / Waveform Capnography
Attach immediately. Confirm waveform present. Normal arrest EtCOโ‚‚ 1โ€“2 kPa.
3
F โ€” Filter
HME filter + catheter mount on all advanced airway devices. Reduces dead space.
4
R โ€” Route (SGA โ†’ Intubation)
SGA first (iGel/LMA). Intubate only if >95% success rate, skill maintained, capnography available. Video laryngoscopy preferred.
Minimise pre-shock pause <5 secs. Resume CPR immediately after shock.
Non-Shockable Rhythm โ€” Asystole / PEA

Non-Shockable Protocol

Continue high-quality CPR. No shock indicated. Identify and treat reversible causes.
Adrenaline 1mg (1:10,000) IV/IO โ€” Give AS SOON AS POSSIBLE, then every 3โ€“5 minutes

Airway โ€” BEFR Order

1
B โ€” BVM
OPA/NPA adjunct. Gentle 1-second breaths. Visible chest rise.
2
E โ€” EtCOโ‚‚
Attach immediately. Monitor waveform continuously.
3
F โ€” Filter
HME filter + catheter mount on all advanced airways.
4
R โ€” Route (SGA โ†’ Intubation)
SGA first. Intubate only if skilled + capnography available.

CPR Cycle

Continue 2-minute CPR cycles. Rhythm check every 2 minutes.

After 2-minute CPR cycle โ€” rhythm check
Reversible Causes โ€” 4Hs and 4Ts
Tap any suspected cause for management guidance. Address in parallel with ongoing CPR.
4 Hs
๐Ÿ’จ Hypoxia
Ensure effective ventilation with 100% Oโ‚‚. Confirm airway patent โ€” consider FB obstruction. Check capnography waveform. Consider SGA or intubation if not already in situ.
๐Ÿฉธ Hypovolaemia
Consider in trauma, haemorrhage, sepsis, dehydration. Control catastrophic haemorrhage. Restore volume rapidly IV/IO with 0.9% NaCl. Early transport. Do NOT give fluids in cardiac arrest without hypovolaemic cause.
โš—๏ธ Hypo/Hyperkalaemia & Hypoglycaemia
Check BM during arrest (IO/IV sample acceptable). Treat hypoglycaemia immediately โ€” significant brain injury risk. Hyperkalaemia: dialysis fistula, renal history, DKA. Hypokalaemia: frailty, eating disorder, gastric illness. Consider time-critical transfer for metabolic arrest.
๐ŸงŠ Hypothermia
Core temp <35ยฐC. Max 3 shocks if <30ยฐC โ€” withhold further until >30ยฐC. Single Adrenaline 1mg + Amiodarone 300mg only if temp out of range/<30ยฐC. 30โ€“35ยฐC: Adrenaline doubled interval (6โ€“10 min). Target ECMO/ECLS centre. Do NOT terminate pre-hospital. Remove wet clothing, prevent further cooling.
4 Ts
๐Ÿ’จ Tension Pneumothorax
High suspicion in trauma, asthma. Needle thoracocentesis if suspected โ€” do not delay. May recur if cannula blocked/dislodged. Maintain high index of suspicion throughout arrest. Bilateral decompression will not worsen situation.
โค๏ธ Cardiac Tamponade
Occult diagnosis. Compresses heart โ€” urgent decompression required. Time-critical transfer to hospital if suspected. Consider PHEC for pericardiocentesis. Ultrasound if available.
๐Ÿ”ด Thrombosis (Coronary / PE)
Coronary: Follow ALS algorithm. Local PPCI / ECMO pathway if refractory VF. Consider by 3rd shock.

PE: History of SOB, DVT, immobility. Time-critical hospital transfer if suspected. Thrombolysis: CPR for up to 90 minutes required. Consider mechanical CPR. Intra-arrest thrombolysis per local pathway.
โ˜ ๏ธ Toxins / Overdose
Crew safety โ€” cross-contamination priority. Transport to ED with ongoing CPR. Consider mCPR for prolonged attempt. Pre-alert ED with suspected substance. Opioid OD: Naloxone if strongly suspected โ€” does not delay other interventions. Prolonged resuscitation appropriate โ€” good neurological outcomes possible. Cessation only with senior clinical advice.
Special Circumstances
Termination of Resuscitation โ€” JRCALC 2026
โš ๏ธ Start time = when first dispatched resource confirms cardiac arrest. First monitored rhythm determines the pathway. This tool supports โ€” it does not replace โ€” clinical judgement and senior advice.

Always Continue โ€” Never Terminate

  • Hypothermia as primary cause of arrest
  • Suspected drug overdose / poisoning
  • Pregnancy

Do Not Start / Stop Immediately

  • Valid DNACPR decision in place
  • Valid ADRT (Advance Decision to Refuse Treatment)
  • Health & Welfare Lasting Power of Attorney refusing CPR
  • ReSPECT plan with DNACPR documented
  • End of life / dying phase โ€” advanced irreversible condition
  • Advanced clinical frailty โ€” resuscitation may not be in best interests
Exception: Sudden unexpected arrest not in line with prognosis (e.g. choking, OD) โ€” commence CPR and address cause even with DNACPR.

Somatic Criteria โ€” Conditions Incompatible with Life

Do not attempt resuscitation if any present. Obtain 30-second rhythm strip (asystole) where possible.

  • Decapitation
  • Massive cranial / cerebral destruction
  • Hemicorporectomy or similar catastrophic injury
  • Burns >95% full thickness
  • Extensive incineration incompatible with life
  • Decomposition / putrefaction
  • Prolonged submersion (refer to Drowning guideline)
  • Post-mortem hypostasis (dependent lividity)
  • Rigor mortis (not cadaveric spasm โ€” see note)
โš ๏ธ Do not view somatic criteria in isolation โ€” collateral history essential. Cold centrally + recent witnessed arrest = resuscitate regardless of lividity.
45-Minute Pathway โ€” Select Presenting Rhythm

Based on the FIRST monitored rhythm at confirmation of arrest.

ROSC Definitions

Sustained vs Transient ROSC

Sustained ROSC = rhythm with output lasting โ‰ฅ10 minutes
Transient ROSC = rhythm with output lasting <10 minutes

For patients who had sustained ROSC then re-arrested โ€” seek senior clinical advice if still in arrest at 45 minutes from confirmation of arrest.

After Termination โ€” Verification of Death

5 minutes of continuous asystole required before verification of death can be completed.
  • Paramedic diagnosing death must complete verification
  • Document all times โ€” arrest confirmation, drugs, shocks, TOR decision, asystole period
  • Record senior clinician name + advice given (via EOC recorded line)
  • Follow local verification of death policy

Favourable Factors โ€” Consider Continuing

๐Ÿ“ž Any doubt โ€” always seek senior clinical advice before terminating. Record name, discussion and advice via EOC on a recorded line.
Arrest Summary
JRCALC 2026 ยท Aide-Memoire ยท Not a legal document
โš ๏ธ This is an aide-memoire only. Complete your full patient care record separately. Times are approximate โ€” verify against CAD and equipment logs.
Final Outcome

๐ŸŸข ROSC

Return of Spontaneous Circulation

Immediate post-ROSC:
โ€ข Confirm with EtCOโ‚‚ โ€” sustained waveform + rising value
โ€ข Check BP, SpOโ‚‚, 12-lead ECG
โ€ข Target SpOโ‚‚ 94โ€“98%, avoid hyperoxia
โ€ข Target normocapnia โ€” do not hyperventilate
โ€ข BM check โ€” treat hypoglycaemia
โ€ข Consider PPCI pathway / STEMI
โ€ข Temperature management
โ€ข Consider PHEC / senior clinical advice
โ€ข Document times โ€” arrest, drugs, shocks, ROSC