Declare the pathway: operation/date, rhythm, perfusion, epicardial wires and immediate reopening capability.
A

First intervention

monitored postoperative arrest
No delay
PEAStart CPR immediately. Assess reversible causes and prepare appropriate early reopening.
Other arrest / electrical intervention unavailableStandard ACLS. Prompt CPR, indicated defibrillation and surgical/device expertise.
  • VF/pVT · trained team + ready defibrillator Three consecutive shocks within one minute → if unsuccessful, CPR and rapid surgical escalation.
  • Source boundary AHA: witnessed postoperative VF. ERC: VF/pVT.
  • Witnessed asystole / bradycardic arrest Existing wires: immediate pacing and mechanical-capture check → CPR within one minute if unsuccessful.
  • One-minute ceiling Only immediately available electrical attempts. Perform the electrical attempt immediately. Do not wait out the minute. Fresh sternotomy does not justify withholding CPR.
B

Prepare reopening from the outset

expertise + equipment
STS / ERC target
Within 5 minutes
Refractory postoperative arrest. STS includes at least the first 10 postoperative days.
AHA 2025
Maintain perfusion
External compressions when emergency resternotomy is not immediately available. Rapid reopening requires a staffed/equipped ICU.
C

Parallel actions

leader + electrical + perfusion + rescue
  • Mobilize Defibrillator, reopening kit, surgeon, anesthesia, blood bank and perfusion. Supply oxygen and assess airway.
  • Handoff Valve/CABG deterioration assessment: preceding operation and findings.
Organized or paced ECG ≠ cardiac output. Assess responsiveness, breathing and reliable perfusion.
A

Recognize collapse

arrest versus severe shock
  • Flat arterial trace Collapse or line problem. Resolve promptly without delaying resuscitation when arrest is evident.
  • Reopening context Index admission, access and rescue capability. Beyond postoperative day 10, individualize with the surgeon.
B

Communicate response-changing facts

not a risk score
  • Operation / date Sternotomy, minimally invasive access, recent valve/graft repair or catheter procedure.
  • Anatomy Grafts, valve/prosthesis, aorta, residual lesions and re-entry risk.
  • Rhythm / wires Pacing dependence, connections and prior capture. Assess AV synchrony when perfusion deteriorates despite an adequate rate.
  • Preceding event Bleeding/drains, ischemia, hypoxemia, line/drug administration or interrupted support.
  • Support Ventilator, vasoactive/inhaled therapy, LVAD, IABP, Impella or ECMO configuration.
  • Rescue Reopening operator, anesthesia/TEE, blood and perfusion/cannulation team.
C

Act before arrest

trajectory + mechanism
  • Escalate Rising support, ischemia, falling output, worsening oxygenation, persistent bleeding or abrupt capture loss → immediate reassessment.
  • Corrective team Name suspected mechanism. Call the team able to treat it while resuscitation continues.
  • Admission plan Pathway, wires, reopening access, equipment and expertise. Revisit after major clinical changes.
VF/pulseless VT → unsynchronized shock. A pulse changes the pathway.
A

Arrest: defibrillation or pacing

confirm rhythm + perfusion
AHA initial biphasic shock
Manufacturer-recommended energy
Commonly 120–200 J initially. Maximum available if the recommendation is unknown. Later shocks: equivalent or higher energy. Check pads.
STS epicardial pacing
DDD 80–100/min
Maximum atrial/ventricular output when this configuration is available. Check wires/generator.
  • Three stacked shocks Applicable monitored postoperative pathway only. AHA: witnessed VF, trained staff. ERC: VF/pVT.
  • Next action Restore circulation or promptly start CPR. Otherwise use the standard single-shock/CPR sequence.
  • Mechanical capture Arterial pressure/output, not only pacing spikes followed by QRS complexes.
  • Unavailable / ineffective pacing Start CPR. Trained operator may briefly pause pacing to uncover VF, minimizing perfusion interruption.
B

Rhythms with circulation

treat instability and mechanism
SituationElectrical / initial treatment
Tachyarrhythmia causing shock, ischemia or acute HFPrompt synchronized cardioversion when synchronization is possible
Sustained polymorphic VTImmediate unsynchronized shock
Symptomatic bradycardiaSupport perfusion, treat cause, select pacing/drugs
Secondary sinus tachycardiaTreat bleeding, hypoxia or other cause. Rate alone is not a cardioversion indication
C

AF / flutter cardioversion

AHA 2025 · initial biphasic energy
AF
≥200 J
Confirm synchronization before every shock.
Flutter
200 J
Sedate if feasible without delaying treatment of critical instability.
Effective compressions first. Airway and monitoring tasks run alongside perfusion support.
A

Adult CPR anchors

AHA 2025
Compressions
100–120/min
At least 5 cm deep, avoiding depths >6 cm. Full recoil, minimal interruptions.
No advanced airway
30:2
Change compressor about every 2 minutes, sooner with fatigue.
Advanced airway
1 breath / 6 seconds
Continuous compressions. Avoid excessive ventilation.
B

Airway and intrathoracic pressure

correct while CPR continues
  • Tube / oxygen Position, patency, supply, chest movement and ventilation. Maximal feasible inspired oxygen during arrest.
  • Circuit / tension Assess ventilator failure or trapped pressure. Treat suspected tension pneumothorax immediately.
  • Postoperative PEEP STS/ERC: reduce/remove during immediate resuscitation.
  • Reassess Anesthesia/respiratory staff restore appropriate PEEP as circulation and oxygenation recover.
C

Read perfusion and response

CPR targets ≠ post-ROSC targets
  • Arterial waveform Compression pressure, circulation and response.
  • Capnography Airway confirmation, ventilation/perfusion trend and possible ROSC.
  • ECG / TEE Rhythm despite pacing/artifact. Focused echo without prolonged interruptions.
  • Possible ROSC Sustained abrupt ETCO2 rise or returning arterial waveform.
  • Termination Low ETCO2 alone must not determine termination.
STS / ERC external CPR
Systolic impulse >60 mm Hg
Poor pressure despite good technique → assess tamponade/profound volume loss. Neither a standalone diagnosis nor a post-ROSC BP target.
Treat the reversible cause while sustaining perfusion. Assign findings to one clinician reporting to the leader.
A

Surgical causes

clue → corrective action
  • Tamponade / retained clot Abrupt low output, pressure/drain change, echo → urgent surgeon, imaging and reopening decision.
  • Bleeding / volume loss Drains/wound, loss and perfusion → blood bank, source control, loss-matched resuscitation.
  • Graft / coronary compromise New ECG/regional dysfunction or recurrent VF → immediate coronary/surgical treatment decision.
  • Valve / mechanical failure Acute postrepair/replacement failure or obstruction → TEE and surgeon.
  • RV / pulmonary crisis RV findings, ventilation change or interrupted support → oxygenation, hemodynamic and RV-support plan.
  • Pulmonary thrombosis Abrupt RV strain/hypoxemia → urgent PE reperfusion/rescue assessment, including recent operative bleeding risk.
  • Airway / tension Hypoxemia, airway pressure, unequal ventilation or difficult bagging → airway correction, immediate decompression when indicated.
B

Other reversible causes

operation + standard framework
  • Pacing / conduction Bradycardia, wire/generator failure or absent mechanical capture → rhythm-specific electrical treatment.
  • Metabolic / drug Potassium, glucose, temperature, recent drug/line flush → cause-specific treatment and exposure review.
C

Use echo to answer a treatment question

never delay definitive rescue
  • Question Localized tamponade, ventricular failure, filling, valve complication or ischemia. Postoperative TTE windows may be limited, especially posteriorly.
  • Expert TEE May inform treatment during CPR. Do not delay indicated reopening or unnecessarily interrupt compressions.
  • Refractory postoperative PEA Serial empiric drugs must not replace surgical assessment. This differential is not a diagnostic rule.
  • Parallel data Blood gas, electrolytes and exposures. Operative echo/tamponade assessment.
Prepare reopening during the first interventions. STS/ERC target: within 5 minutes, not a waiting interval.
A

Escalate while maintaining perfusion

surgical rescue
Perfusion support and surgical rescue run in parallelRecognize arrest and begin the applicable immediate intervention. Prepare surgical rescue from the outset. Maintain perfusion while the trained team prepares reopening. The five-minute target is not a waiting interval.Recognize + act immediatelyImmediate rhythm-specific action(page 1).Maintain effective perfusionPrepare reopening in parallelfrom the outset.Definitive rescuefor refractory arrestTrained team + access/equipment.STS/ERC reopening goal:within 5 minutes.
Illustrative sequence, not a resuscitation timer. The one-minute electrical ceiling applies only to the selected witnessed postoperative rhythms on page 1. Preparation begins immediately.
B

Assign work aloud

combine roles only until help arrives
  • Leader Pathway, findings, decisions and rescue request.
  • Electrical Defibrillator, wires/generator, pacing and rhythm.
  • Compressor Effective CPR, changes and immediate restart after necessary pauses.
  • Airway / anesthesia Oxygenation, tube/circuit, capnography, anesthesia/TEE.
  • Drugs / access Drug, dose, route, time and infusion review.
  • Reopening operator / assistant Trained, procedure-appropriate rescue and internal resuscitation.
  • Perfusion / blood Cannulation/ECLS or bypass readiness, blood/products.
  • Recorder Clock, rhythm, interventions, response, circulation and decisions.
C

Equipment and competence

immediately available
  • STS reopening set Marked scalpel, wire cutter, heavy needle holder, sternal retractor, suction and appropriate drapes/scissors. Check availability.
  • Internal rescue Accessible internal defibrillation and full surgical set. Trained operators for reopening/internal massage.
  • Evidence AHA 2025: observational resternotomy evidence, no randomized trial. Simulation, equipment checks and staff competence support execution.
State the drug, dose, route and phase: arrest, peri-arrest or post-ROSC. Record response.
A

Epinephrine: declare the pathway

keep AHA, STS and ERC distinct
Source
boundary
AHA 2025 · standard adult arrest1 mg IV/IO every 3–5 minutes. Nonshockable: as soon as feasible. Shockable: after initial defibrillation attempts.
STS 2017 · fresh cardiac surgeryAvoid routine epinephrine/vasopressin unless directed by an experienced clinician. Concern: severe hypertension/bleeding after circulation returns.
ERC 2025 · fresh cardiac surgerySummary: reduced IV epinephrine 0.05–0.1 mg. Text: 50–100 mcg peri-arrest boluses.
  • AHA postoperative pathway Unsuccessful pacing → standard ACLS. AHA retains standard epinephrine. No universal postoperative prohibition.
  • Reduced-bolus strategy Agree in advance. Experienced leader, prepared concentration and explicit order. No improvised dilution or automatic substitution in every CTICU arrest.
B

Other standard ACLS doses

AHA 2025 · indication matters
IndicationDose / next step
VF/pVT refractory to shocksAmiodarone 300 mg IV/IO, then 150 mg OR lidocaine 1–1.5 mg/kg, then 0.5–0.75 mg/kg
Symptomatic bradycardia with pulseAtropine 1 mg IV every 3–5 minutes to 3 mg total
Atropine ineffectivePacing and/or dopamine 5–20 mcg/kg/min or epinephrine 2–10 mcg/min
Stable wide-QRS VT infusionAmiodarone 150 mg over 10 minutes, then 1 mg/min for the first 6 hours. Distinct from arrest bolus
C

Avoid medication-driven delay or harm

cause-specific decisions
  • Calcium / bicarbonate / magnesium Cause-specific use. Not routine in undifferentiated arrest.
  • Infusions Stop nonessential or contributory treatment. Preserve therapy required for resuscitation.
Assess effective perfusion and actual support configuration. Call device/perfusion expertise early.
A

Identify support and failure

displayed flow alone is insufficient
  • Durable LVAD Perfusion, power/controller/driveline and function. Pulse may normally be absent.
  • Balloon pump Function, trigger and relationship to rhythm/pressure.
  • Impella / temporary pump Flow, alarms, position, preload/RV reserve and team-directed troubleshooting.
  • VA-ECMO Effective circuit flow and systemic oxygen delivery, not electrical rhythm alone.
  • VV-ECMO Respiratory support. Does not provide VA-ECMO circulatory function.
  • Possible ECPR Team/resources, access, reversible mechanism and rapid candidacy decision.
B

LVAD: inadequate perfusion + unresponsiveness

support circulation promptly
CPR
priority
ResuscitationPrioritize CPR. Another rescuer checks the device when available. Do not delay circulation support solely for pump troubleshooting.
  • Device changes Actual device protocol and trained operator. Communicate configuration, flow, alarms and suspected mechanism.
C

Postoperative extracorporeal rescue

selected patients + capable system
  • AHA 2025 ECLS can be useful in selected refractory postoperative arrests.
  • ERC 2025 Consider ECPR after failed reopening or when minimally invasive access/later timing changes rescue. Resource-dependent.
  • Parallel treatment Treat the surgical cause. Name candidacy decision-maker, cannulation and support teams.
  • Record mechanism Extracorporeal restoration of circulation is distinct from ROSC due to native cardiac activity.
Confirm sustained perfusion. Record what restored circulation, current rhythm/support and unresolved surgical cause.
A

Post-arrest targets

AHA 2025
Oxygen
SpO2 90–98%
Initially 100% oxygen until reliable measurement. Alternative target: PaO2 60–105 mm Hg.
Comatose ventilation
PaCO2 35–45 mm Hg
General target. Check blood gas. ETCO2 is not interchangeable.
Pressure
MAP ≥65 mm Hg
Minimum. Avoid hypotension, individualize to perfusion/operation.
Unresponsive to verbal commands
32–37.5 °C
Deliberate temperature control for at least 36 hours.
B

Reassess the operation and cause

before declaring stability
  • Cause ECG, targeted imaging, hemodynamics and treatment.
  • Immediate review Drains/bleeding, ECG, LV/RV/valves, oxygenation and support trajectory.
  • Persistent ischemia / mechanical dysfunction Specific coronary/surgical assessment.
  • Troponin Postoperative elevation alone neither identifies graft failure nor determines rescue.
C

Neurologic assessment

confounders + multimodal prognosis
Prognostic interpretation
≥72 hours
After BOTH normothermia and sedative discontinuation. Do not start the clock at arrest.
  • Examination Commands, sedation/paralysis, seizures/myoclonus. EEG when indicated.
  • No single-test conclusion Early examination, isolated ETCO2 or myoclonus cannot establish prognosis. Control confounders, use multimodal assessment.
  • Handoff Reassessment team/time, recurrent-arrest prevention, medication reconciliation and family communication.
Every shift: known roles, working equipment and an executable surgical/device pathway.
A

Readiness check

adaptable template, not completed institutional readiness
  • Electrical Defibrillator/pads, energy/synchronization, wires, generator/cables and capture.
  • Surgical Reopening kit, suction, sterile equipment, internal defibrillation, trained operators and backup access.
  • Experts Blood bank, anesthesia/TEE and perfusion/ECLS.
  • Drugs / airway Agreed epinephrine strategy/prepared concentrations, airway, capnography, IV/IO and clock/recorder.
  • Devices Known device-specific response plan.
B

Event handoff

time + intervention + response
  • Arrest [Time, operation/date/POD, witnessed/monitored status, initial rhythm/perfusion]
  • Pathway [Surgical, standard ACLS or device-specific]
  • Electrical [Shock times/energy, pacing settings/mechanical capture]
  • CPR / airway [Start, interruptions, ventilation, monitoring]
  • Medicines [Dose/route/time, surgical strategy, response]
  • Cause [Bleeding, tamponade, ischemia, valve, RV, respiratory, metabolic/drug, device]
  • Rescue / ECLS [Decision, activation, intervention times]
  • Circulation [Time, native versus extracorporeal, rhythm/perfusion/support, unresolved problem]
  • Post-arrest [Cause, oxygen/ventilation/BP, temperature/neuro, recurrence prevention, teams]
  • Communication [Family discussion, debrief completed/pending, owner]
C

Debrief and simulation

elapsed time + barriers
  • Test execution Recognition, electrical treatment, perfusion, reopening and rescue activation. Review delays/barriers as well as checklist adherence.
  • Related decisions Anticoagulant reversal · valve/CABG plan.