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OR Cardiac Arrest

ACLS adapted for the operating room: anesthetic depth, surgical bleeding/positioning/embolism are reversible causes the medicine code team won't think of first.

Recognition

  • •Loss of pulse on art line / pulse ox / ETCO₂ drop
  • •Asystole, PEA, V-fib/V-tach on monitor
  • •Sudden bradycardia → arrest in MH, LAST, sympathectomy

Steps

  1. 1
    Call code, start CPR (100–120/min, depth 5 cm), 100% O₂
  2. 2
    Reduce/stop volatile + vasodilators
    Anesthetic depth is a uniquely OR cause.
  3. 3
    Surgical pause + control hemorrhage
    Surgeon should pack + apply pressure; turn off insufflation.
  4. 4
    Reposition supine + LUD if pregnant
    Prone CPR is feasible if access prevents repositioning.
  5. 5
    Standard ACLS drugs at standard doses (except LAST + bupivacaine)
  6. 6
    Reverse causes — Hs/Ts + OR-specific
    Hypovolemia, hypoxia, H⁺ acidosis, hypo/hyperkalemia, hypothermia, tension pneumo, tamponade, toxins (anaphylaxis, MH, LAST), thrombosis (PE/MI), trauma.
  7. 7
    TEE if available for cause + monitoring response
  8. 8
    Consider ECMO if refractory + reversible cause

Drugs + doses

DrugDoseNote
Epinephrine1 mg IV q3–5 min (standard; ≤100 mcg in LAST)
Amiodarone300 mg IV bolus, then 150 mg
Calcium chloride1 g IV (hyperkalemia, CCB toxicity)
Bicarb1 mEq/kg (severe acidosis, hyperkalemia, TCA OD)

Pitfalls

  • !If patient was just induced — anesthetic depth is the cause until proven otherwise.
  • !Code team will not know about the surgical site; you must direct.
  • !EtCO₂ < 10 during CPR predicts poor outcome — push harder, give vasopressor.

Sources

  • AHA ACLS 2020 Update
  • Moitra Anesth Analg 2018
  • Society Cardiothoracic Anesthesia Cardiac Arrest

Anatomy reference

Sourced reference images. 4 matches for "heart cardiac chambers ventricle".

Heart_and_cardiac_blood_vessels,_1717._Wellcome_L0000338
Wikimedia · CC BY 4.0
Heart_anterior_normal_ventricles
Wikimedia · CC BY 2.5
Heart_anterior_ventricles_valves
Wikimedia · CC BY 2.5
Heart_oblique_ventricles
Wikimedia · CC BY 2.5
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Education only — not a substitute for facility protocols, MOC certification, or clinical judgment. Always follow your institutional crisis algorithm and confirm doses against current package inserts.