Intravenous (IV) access is preferred during or after cardiac arrest over intraosseous (IO) access.
If IV access is not rapidly achieved within two attempts, consider IO access as an alternative.
For non-shockable rhythms (pulseless electrical activity/asystole), give 1mg adrenaline (epinephrine) as soon as feasible during CPR and then every second loop of the ALS algorithm.
Give 1mg adrenaline for shockable rhythms (VF/pulseless ventricular tachycardia (pVT)), if initial two defibrillation attempts are unsuccessful and after every second loop of the ALS algorithm.
Vasopressin and corticosteroids are unlikely to be helpful.
Give 300mg amiodarone for shock-refractory VF/pVT during CPR (after 3rd shock, if still refractory give an additional dose of 150mg after the 5th shock.
Give 1mg/kg lidocaine as an alternative to amiodarone in shock-refractory VF/pVT. If still refractory an additional dose of 0.5mg/kg may be considered.
Calcium is unlikely to help, particularly in in-hospital cardiac arrest (IHCA).
Calcium, magnesium, potassium, sodium bicarbonate (and other buffers) may help pre-existing conditions.
Do not give fibrinolytics routinely unless pulmonary embolus suspected.
doi: 10.1016/j.resuscitation.2025.110769
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