Resuscitation is a foundational domain in the ACEM fellowship exam, with the airway/resuscitation topic group accounting for approximately 10 of the 120 SCQ questions. Fellowship-level questions go well beyond basic ALS algorithms — they test nuanced decision-making around reversible causes, medication timing, airway strategies in difficult situations, post-resuscitation care pathways, and cardiac arrest in special circumstances. This guide is referenced to the ILCOR 2025 Consensus on Science with Treatment Recommendations (CoSTR) and current ANZCOR guidelines.
Adult ALS algorithm — ANZCOR Guideline 11.2
The ANZCOR adult ALS algorithm is the framework the exam expects you to apply. Both papers are completed on the same day and use a 2-minute CPR cycle with rhythm checks at each cycle.
Shockable rhythms (VF/pVT)
- Deliver a single shock, then immediately resume CPR for 2 minutes before the next rhythm check
- Adrenaline 1 mg IV/IO after the 2nd unsuccessful shock, then every second loop (i.e. every 4 minutes)
- Amiodarone 300 mg IV after the 3rd unsuccessful shock, followed by a further 150 mg if VF/pVT persists
- For refractory VF/pVT (persisting after ≥3 shocks), ILCOR 2025 suggests considering double sequential defibrillation (weak recommendation, low-certainty evidence) or vector change defibrillation. If using DSDeF, a single operator should activate the defibrillators in sequence
Non-shockable rhythms (PEA/asystole)
- Adrenaline 1 mg IV/IO as soon as feasible (do not wait for two cycles), then every second loop
- Search aggressively for reversible causes (4Hs and 4Ts) — PEA with a narrow complex has a higher likelihood of a treatable cause
- No role for amiodarone in non-shockable rhythms
Exam point: The key distinction in adrenaline timing is that in shockable rhythms it is delayed until after the 2nd shock, whereas in non-shockable rhythms it is given as soon as IV/IO access is obtained. This difference is frequently tested.
Medications in cardiac arrest — ANZCOR Guideline 11.5
| Drug | Dose | Indication | Notes |
|---|---|---|---|
| Adrenaline | 1 mg IV/IO every 2nd loop (~4 min) | All cardiac arrest rhythms | Early in non-shockable; after 2nd shock in shockable. ILCOR 2025 suggests 1 mg every 3–5 min |
| Amiodarone | 300 mg IV, then 150 mg | Refractory VF/pVT after 3rd shock | Dilute in 20 mL glucose 5%. Can cause hypotension |
| Lignocaine | 1–1.5 mg/kg IV | Alternative to amiodarone if unavailable | ILCOR 2025: amiodarone and lignocaine given equal status |
| Sodium bicarbonate | 1 mmol/kg (8.4%) | Hyperkalaemia, TCA toxicity, severe metabolic acidosis | Not routinely recommended in cardiac arrest |
| Calcium chloride | 10 mL of 10% (6.8 mmol) | Hyperkalaemia, hypocalcaemia, calcium channel blocker toxicity | Give via central line if possible; causes tissue necrosis if extravasated |
| Magnesium | 5 mmol (2.5 g) IV | Hypomagnesaemia, torsades de pointes | Give over 1–2 min in arrest |
Vascular access
IV access is the preferred route (ANZCOR, ILCOR 2025 — weak recommendation, low-certainty evidence). If IV access cannot be achieved within two attempts, IO access is a reasonable alternative. Adrenaline, lignocaine, and atropine can be given via endotracheal tube, but other cardiac arrest drugs should not be given by this route as they may cause mucosal and alveolar damage.
Reversible causes — the 4Hs and 4Ts
The 4Hs and 4Ts framework is basic, but the exam tests your ability to identify the specific reversible cause in a clinical scenario and implement targeted treatment during CPR.
| 4Hs | 4Ts |
|---|---|
| Hypoxia — ensure adequate ventilation and oxygenation | Tension pneumothorax — finger thoracostomy (bilateral in arrest) |
| Hypovolaemia — volume resuscitation, haemorrhage control | Tamponade — pericardiocentesis or emergency thoracotomy |
| Hyperkalaemia / electrolytes — calcium, insulin/dextrose, bicarbonate | Toxins — specific antidotes (see toxicology guide) |
| Hypothermia — active rewarming, prolonged resuscitation | Thrombosis (PE or coronary) — thrombolysis, PCI, or embolectomy |
Airway management
Fellowship-level airway questions focus on decision-making rather than technique. Key areas include the anticipated difficult airway (predictors, preparation, and Plan A/B/C approach), RSI drug selection for specific clinical contexts (head injury, status epilepticus, sepsis, raised ICP), front-of-neck access indications and technique, and post-intubation management.
RSI drug selection
| Context | Induction agent | Rationale |
|---|---|---|
| Haemodynamically stable | Propofol 1.5–2 mg/kg or ketamine 1.5–2 mg/kg | Standard agents |
| Raised ICP / head injury | Propofol (or thiopentone) + rocuronium | Avoid ketamine historically, though evidence for ICP elevation is weak; propofol reduces ICP |
| Haemodynamic instability / sepsis | Ketamine 1–1.5 mg/kg | Maintains SVR and cardiac output; avoid propofol (causes hypotension) |
| Status epilepticus | Propofol or thiopentone | Both have anticonvulsant properties; ketamine as adjunct (NMDA antagonist) |
| Anaphylaxis with airway oedema | Ketamine | Bronchodilator properties, maintains haemodynamics |
CICO — can’t intubate, can’t oxygenate
The CICO scenario is a favourite exam topic. Know the triggers for declaring CICO (failure of Plan A intubation and Plan B supraglottic airway with desaturation and inability to oxygenate) and the steps that follow. ANZCOR Guideline 11.6 states that when standard airway strategies have failed, appropriately trained rescuers should attempt front-of-neck airway access using a cricothyroidotomy technique. The scalpel-bougie-tube technique is the recommended surgical approach: vertical skin incision, horizontal stab through the cricothyroid membrane, bougie insertion, and railroading a size 6.0 cuffed ETT.
Shock states
You must be able to classify shock (hypovolaemic, cardiogenic, distributive, obstructive) and identify the specific cause within each category based on clinical and investigation findings. The exam frequently presents undifferentiated shock scenarios where multiple causes are possible.
| Shock type | Key exam topics | Management principles |
|---|---|---|
| Septic shock | Surviving Sepsis 2021 guidelines, hour-1 bundle, vasopressor selection | 30 mL/kg crystalloid within 3 hours (reassess); noradrenaline first-line vasopressor; add vasopressin if MAP target not met; hydrocortisone 200 mg/day if refractory |
| Cardiogenic shock | Acute MI with cardiogenic shock, acute heart failure | Avoid excessive fluid; noradrenaline or adrenaline for pressor support; early PCI for STEMI; consider inotropes (dobutamine, milrinone) |
| Obstructive shock | Massive PE, tension pneumothorax, cardiac tamponade | PE: systemic thrombolysis if massive with haemodynamic compromise — tenecteplase weight-based single IV bolus (e.g. 50 mg for 60–90 kg) is preferred in the ED setting for ease of administration; alteplase 100 mg over 2 hours is an alternative. Tension: immediate decompression. Tamponade: pericardiocentesis or thoracotomy |
| Anaphylaxis | Adrenaline dosing, refractory management, biphasic reactions | Adrenaline 0.5 mg IM (1:1000) repeated every 5 min; IV adrenaline infusion for refractory cases; glucagon 1–5 mg IV if on beta-blockers |
| Hypovolaemic shock | Haemorrhagic shock classification, massive transfusion | Damage control resuscitation; 1:1:1 ratio PRBC:FFP:platelets; TXA 1 g within 3 hours of injury; permissive hypotension (SBP 80–90) until haemostasis in trauma |
Post-resuscitation care — ANZCOR Guidelines 11.7 and 11.8
Temperature control
Temperature management recommendations have evolved significantly. Based on ILCOR 2025 CoSTR and ANZCOR Guideline 11.8:
- ANZCOR suggests actively preventing fever by targeting a temperature ≤37.5°C for patients who remain comatose after ROSC (weak recommendation, low-certainty evidence)
- Whether subpopulations (e.g. shockable initial rhythm OHCA) benefit from hypothermia at 32–34°C remains uncertain
- Patients with mild hypothermia after ROSC should not be actively warmed to normothermia
- Maintain temperature control for at least 24 hours after ROSC
- Avoid and treat fever (≥37.8°C) for at least 72 hours after ROSC
Exam point: The shift from aggressive hypothermia (32–34°C as per TTM1 trial) to fever prevention (≤37.5°C, supported by TTM2 trial) is a high-yield exam topic. Know the evolution: HACA 2002 → TTM1 2013 (33°C vs 36°C, no difference) → TTM2 2021 (hypothermia vs normothermia, no difference) → ILCOR 2025 recommendation for fever prevention.
Coronary angiography post-arrest
- STEMI on post-ROSC ECG: Immediate coronary angiography and PCI within 120 minutes, as per standard STEMI pathways. Activate existing STEMI networks
- No STEMI: Routine immediate angiography is not superior to a delayed/selective strategy (COACT trial, TOMAHAWK trial). Individualise decision based on clinical features and arrest characteristics
- Comatose patients with STEMI: proceed to PCI — do not delay for neurological assessment
- Awake patients post-arrest with STEMI: outcomes comparable to STEMI patients who were not in arrest; treat as standard STEMI
Post-ROSC bundle
- Ventilation: Target normocapnia (PaCO2 35–45 mmHg) and normoxia (SpO2 94–98%). Avoid hyperoxia and hypocapnia as both worsen neurological outcomes
- Haemodynamics: Maintain MAP ≥65 mmHg (ILCOR 2025 suggests ≥60–65 mmHg). Use noradrenaline or adrenaline as needed
- Glucose: Monitor frequently; target normoglycaemia; treat hyperglycaemia (>10 mmol/L) with insulin; avoid hypoglycaemia
- Seizures: Treat clinical seizures and electrographic status epilepticus. EEG monitoring recommended from day 1 post-ROSC
Neuroprognostication
Neuroprognostication after cardiac arrest uses a multimodal approach and should not be performed before 72 hours after ROSC (or 72 hours after rewarming if hypothermia was used). No single test should be used in isolation. The ERC/ESICM 2025 guidelines and ILCOR 2025 recommend:
| Modality | Timing | Poor prognosis indicators |
|---|---|---|
| Clinical examination | ≥72 hours post-ROSC | Bilateral absence of pupillary light reflex and corneal reflexes; myoclonus status within 72 h (in context) |
| EEG | Record from day 1; formal assessment ≥24 h | Suppressed background or burst-suppression without reactivity at ≥24 h. Continuous/routine EEG for 24–48 h also detects non-convulsive status epilepticus |
| NSE (neuron-specific enolase) | Serial at 24, 48, and 72 h | High values at 48–72 h (thresholds vary by assay); rising trend between 24–72 h strongly suggests poor outcome |
| SSEP | ≥24 h post-ROSC | Bilateral absence of N20 cortical potentials (very high specificity for poor outcome) |
| Brain MRI | Days 2–7 post-ROSC | Extensive diffusion restriction in cortex or deep grey matter |
| CT brain | ≥24 h | Generalised cerebral oedema (loss of grey–white differentiation, sulcal effacement) |
Favourable signs: A continuous EEG background without epileptiform discharges within 72 h of ROSC and absence of diffusion restriction on MRI days 2–7 are favourable. When two or more concordant favourable signs are present with no signs of poor outcome, neurological recovery rate exceeds 80%.
Special circumstances — ANZCOR Guideline 11.10
Traumatic cardiac arrest
Traumatic cardiac arrest differs fundamentally from medical arrest. ANZCOR Guideline 11.10.1 priorities:
- Haemorrhage control, restoration of circulating volume, airway opening, and relief of tension pneumothorax have priority over conventional CPR unless a medical cause is suspected to have preceded the trauma
- Bilateral finger thoracostomies should be performed early
- Emergency thoracotomy: more likely to be effective in penetrating trauma than blunt. Favourable outcome is rarely possible if initiated >10 minutes after onset of arrest
- Pericardial tamponade: optimal management is surgical drainage — emergency thoracotomy and pericardiotomy is an acceptable alternative to operating room thoracotomy
Cardiac arrest in pregnancy
- ANZCOR suggests delivery of the fetus by perimortem caesarean delivery (PMCD) for women in cardiac arrest in the second half of pregnancy
- PMCD should be initiated within 4 minutes of arrest onset if there is no ROSC, with delivery aimed by 5 minutes — the purpose is to relieve aortocaval compression and improve maternal resuscitation
- Manual left uterine displacement during CPR from 20 weeks gestation
- Standard ALS algorithm otherwise applies; treat reversible causes (eclampsia, haemorrhage, amniotic fluid embolism, PE)
Drowning
- Cardiac arrest in drowning is secondary to hypoxia — compression-only CPR is likely to be ineffective
- Give 5 initial rescue breaths, supplemented with oxygen if available
- Then standard CPR at 30:2 ratio on a firm surface
- Ventilation and oxygenation are the priority
Hyperkalaemia
- Most common electrolyte cause of life-threatening arrhythmias and cardiac arrest
- In arrest: calcium chloride 10 mL of 10% IV (or calcium gluconate 30 mL of 10%); sodium bicarbonate 50 mmol; insulin 10 units + glucose 50 mL of 50%
- Characteristic ECG changes: peaked T waves → PR prolongation → loss of P waves → widened QRS → sine wave → VF/asystole
Procedural sedation
Procedural sedation questions appear in the written exam because they test pharmacology, risk assessment, monitoring standards, and complication management. Know the commonly used agents, their relative risks, and the management of adverse events.
| Agent | Dose | Onset / Duration | Key considerations |
|---|---|---|---|
| Propofol | 0.5–1 mg/kg titrated | 30–60 sec / 5–10 min | Apnoea risk; hypotension; no analgesic effect — combine with opioid for painful procedures |
| Ketamine | 1–2 mg/kg IV | 1 min / 15–20 min | Dissociative; maintains airway reflexes and haemodynamics; emergence reactions; laryngospasm rare (~0.3%) |
| Fentanyl + midazolam | Fentanyl 1 μg/kg + midazolam 0.02–0.05 mg/kg | 2–3 min / 30–60 min | Respiratory depression; reversed with naloxone/flumazenil; longer recovery |
| Nitrous oxide | 50:50 or 70:30 N2O:O2 | Rapid onset / rapid offset | Minimal sedation; diffusion into air-filled spaces (contraindicated in pneumothorax, bowel obstruction) |
References
- ILCOR. Advanced Life Support: 2025 International Liaison Committee on Resuscitation Consensus on Science with Treatment Recommendations. Resuscitation 2025; Circulation 2025.
- ANZCOR. Guideline 11.2 – Protocols for Adult Advanced Life Support (updated 2025).
- ANZCOR. Guideline 11.5 – Medications in Adult Cardiac Arrest (updated 2025).
- ANZCOR. Guideline 11.6 – Equipment and Techniques in Adult Advanced Life Support.
- ANZCOR. Guideline 11.7 – Post-resuscitation Therapy in Adult Advanced Life Support.
- ANZCOR. Guideline 11.8 – Temperature Control after Cardiac Arrest.
- ANZCOR. Guideline 11.10 – Resuscitation in Special Circumstances.
- ANZCOR. Guideline 11.10.1 – Management of Cardiac Arrest due to Trauma.
- ERC/ESICM. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2025: Post-Resuscitation Care. Resuscitation 2025.
- AHA. Part 9: Adult Advanced Life Support – 2025 American Heart Association Guidelines. Circulation 2025.
- AHA. Part 11: Post–Cardiac Arrest Care – 2025 American Heart Association Guidelines. Circulation 2025.
- Dankiewicz J et al. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest (TTM2). N Engl J Med 2021; 384:2283–2294.
- Lemkes JJ et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation (COACT). N Engl J Med 2019; 380:1397–1407.
- Evans L et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Med 2021; 47:1181–1247.