Emergency Medicine Cases
Emergency Medicine Cases

Ep 216 Cardiac Arrest Update: Beyond the 2025 ACLS Guidelines Part 2 – Medications, Airway, Termination and Post-ROSC Care

April 7, 2026

AI Summary

5 min read

In a 2022 reanalysis of the landmark ALPS trial, giving amiodarone early in refractory VF was associated with improved survival and neurologic outcomes, but the benefit vanished as administration was delayed—likely because of the drug’s hemodynamic side effects. The original trial had aimed to give amiodarone with epinephrine after the first shock, but in practice the first dose still landed at a median of 19 minutes into the arrest. That timing gap is one of the central tensions in this episode: the guidelines are often behind the physiology, and the best interventions only work if you get them in early, before the cascade of rearrest and metabolic collapse takes over.

Vasopressors and Adjuncts: When to Reach, When to Hold

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What you'll learn

  • 1 EP 216: Cardiac Arrest Update – Part 2 (Medications, Airway, Termination, Post-ROSC)
  • 2 (01:30) **Episode Setup** - Introduction to Part 2: moving beyond mechanics to vasopressors, adjunct meds, airway, termination decisions, and post-ROSC care
  • 3 (03:50) **Vasopressin & Steroids Combo** - Why this bundle keeps resurfacing but hasn't entered routine practice
  • 4 (08:04) **Norepinephrine & Push-Dose Epi Post-ROSC** - The critical bridge to prevent re-arrest after ROSC
  • 5 (12:56) **Amiodarone vs. Lidocaine** - Navigating conflicting evidence on antiarrhythmics for shockable rhythms
  • 6 (21:13) **Calcium, Bicarb, and Mag** - When these adjuncts help vs. when they harm
  • 7 (32:07) **Ketamine in Cardiac Arrest** - Sedation for CPR-induced consciousness, not routine neuroprotection

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Show Notes

In this Part 2 or our 2-part EM Cases podcast series on Cardiac Arrest Update, Dr. Sheldon Cheskes and Dr. Rob Simard take us beyond the algorithms and into the real-world decision-making of cardiac arrest care. We answer questions like: Do vasopressin and steroids improve survival or just ROSC? Should we be giving amiodarone earlier—and is lidocaine just as good? When should we use calcium, bicarbonate, or magnesium, and when should we avoid them? What role does ketamine play in CPR-induced consciousness? How should we choose between supraglottic airways and endotracheal intubation? What are the pitfalls of waveform capnography (ETCO2) to help guide CPR quality, detect ROSC, and inform prognosis? What is the role of PoCUS and TEE during cardiac arrest? When should we terminate resuscitation—and how do ETCO2 and POCUS factor into that decision? Should we widen the criteria to consider thrombolytics and who should go to the cath lab, and should we be ordering whole-body CT after ROSC for everyone who isn't going to the cath lab or getting ECMO? And finally, what are the key post-ROSC targets that actually impact neurologic outcomes in cardiac arrest patients? and many more...Please consider a donation to EM Cases to support ongoing high quality Free Open Access Medical Education https://emergencymedicinecases.com/donation/

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