ACLS Algorithms
First Things First (assess for & treat the following)
- The following algorithms are adapted from the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Additional information & references may be obtained from Circulation 2005;112(24 Supplement) and the American Heart Association CPR and Emergency Cardiovascular Care website (www.americanheart.org).
- Identify life-threatening arrhythmias:
- Symptomatic bradycardia
- Symptomatic tachycardia
- Ventricular fibrillation
- Pulseless ventricular tachycardia
- Pulseless electrical activity
- Asystole
- Minimize the time from cardiac arrest recognition to starting effective CPR.
- Assess and control airway.
- Assess breathing and integrate with chest compressions at 2:30 ratio.
- Immediate defibrillation when indicated
- Maximize hemodynamics by effective chest compression, pharmacological and antidysrhythmic treatment.
- Differential diagnosis
History and Physical (assess for the following)
- Obtain prehospital & pre-resuscitation history.
- Medication profile may be helpful.
- Rule out correctable causes of cardiac arrest.
Diagnostic Tests
- Lab studies are seldom useful during initial phase of resuscitation.
- Potentially useful diagnostic tests for ongoing resuscitation:
- ABG
- Base deficit
- Lactate
- Potassium
- Hemoglobin
- Cardiac enzyme injury markers
- CXR
General Management Principles
Adult cardiac arrest (>8 years)
BLS primary survey and algorithm
- Activate emergency response system or 911.
- Call for defibrillator.
- A: Assess (open) airway
- B: Assess breathing
- Yes: Recovery position
- No: 2 breath to chest rise
- C: Assess circulation (pulse check up to 10 seconds)
- Yes: One breath every 6 seconds
- No: Alternate compressions/ventilations 30:2 until AED or ACLS
- PUSH HARD (1-2” depth) AND FAST (100/min) on the chest and ALLOW COMPLETE CHEST RECOIL.
- Attach AED.
- Power ON
- Attach electrode pads.
- Assess rhythm.
- Shockable: Clear and give one shock every 5 compression/ventilation (C/V) cycles of 30:2
- Non-shockable: Immediate CPR for 5 cycles of 30:2 or 2 minutes, then reassess
ACLS secondary survey and algorithm
- A: Assess (open) airway
- Advanced airway when indicated
- B: Assess breathing
- Use 100% oxygen
- O2 saturation and end-tidal CO2 confirmation
- C/V asynchronous
- C: Assess circulation
- Obtain IV access
- EKG differential diagnosis
- Defibrillate if shockable
- Vfib or pulseless Vtach
- Shock
- Shock energy Monophasic 360 J
- Shock energy Biphasic 120 J (rectilinear) or 150 J (truncated), escalate to 200 J (200 J if unknown wave)
- CPR 5 cycles (or 2 minutes)
- Shock
- Pressors
- CPR 5 cycles
- Shock
- Antiarrhythmic
- Shock
- Pressors
- CPR
- Shock
- Asystole or PEA
- CPR
- Pressors
- Atropine
- Differential diagnosis
- CPR
- Vfib or pulseless Vtach
Differential diagnosis
- Hypovolemia
- Hypoxia
- Hydrogen ion—acidosis
- Hyper/hypokalemia & other metabolic causes
- Hypo/hyperthermia
- Hypoglycemia
- Toxins (including drug)
- Tamponade
- Tension pneumothorax
- Thrombosis (acute coronary syndrome and pulmonary embolism)
- Trauma (hemorrhage)
Pharmacotherapy
- Vfib or pulseless Vtach
- CPR (5 cycles or 2 minutes)
- Shock
- Epinephrine IV 1 mg every 3-5 min or Vasopressin IV 40U, X 1 and CPR
- Shock
- Amiodarone 300 mg IV then 150-mg boluses X 1 or lidocaine 1 mg/kg IV then 0.5-mg/kg boluses X 3 doses
- Mg 2 g IV if torsades de pointes and CPR
- CPR
- Asystole or PEA
- CPR
- Epinephrine IV 1 mg every 3-5 min or Vasopressin IV 40U, X 1 and CPR
- Atropine 1 mg IV X 3
- CPR
- Consider transcutaneous pacing
Specific Treatments
Symptomatic bradycardia (HR < 60)
- Primary survey
- Assess ABCs.
- Secure airway noninvasively.
- Ensure monitor/defibrillator is available.
- Secondary survey
- Assess secondary ABCs. (Is invasive airway mgt indicated?)
- O2, IV access, monitor, fluids
- Vital signs, pulse ox, monitor blood pressure
- ECG 12-lead
- CXR
- Problem-focused history
- Problem-focused physical exam
- If signs or symptoms are due to bradycardia:
- Atropine: 0.5-1.0 mg IV q 3-5 min until 0.04 mg/kg
- Transcutaneous pacing if available
- Dopamine: 2-10 mcg/kg/min
- Epinephrine: 2-10 mcg/min
- Prepare for transvenous pacemaker if above interventions are unsuccessful.
Symptomatic tachycardia, unstable (>150 with severe hypotension)
- Synchronized cardioversion algorithm
- Have available at bedside:
- O2 saturation monitor
- Suction device
- IV access
- Intubation equipment
- Premedicate when possible.
- Diazepam: 0.1-0.2 mg/kg IV
- Midazolam: 0.05-0.1 mg/kg IV
- Etomidate: 0.3 mg/kg IV
- Ketamine: 1-2 mg/kg IV
- Methohexital: 1 mg/kg IV
- Turn on defibrillator.
- Attach monitor leads.
- Engage synchronization mode by pressing the “sync” button.
- Identify markers on R waves indicating sync mode.
- If necessary, adjust monitor gain until sync markers occur with each R wave.
- Select appropriate energy level.
- Synchronized cardioversion monophasic at 100 J, 200 J, 300 J, 360 J
- Synchronized cardioversion biphasic at 100 J and escalating
- PSVT & atrial flutter may respond to lower energy levels (start at 50 J).
- Polymorphic VT, treat as Vfib.
- Position conductor pads or gel on patient.
- Position paddle/pads on patient (sternum apex).
- Announce to team members, “charging defibrillator; stand clear.”
- Press charge button.
- When the defibrillator is charged:
- Ensure resuscitation team members are away from & not touching pt.
- Apply 25 lbs of pressure on paddles or use automatic device.
- Press discharge buttons simultaneously.
- Check monitor; if tachycardia persists, increase joules as above.
- Reset sync mode after each synchronized cardioversion because most defibrillators default to the unsynchronized mode. This default allows immediate defibrillation if the cardioversion produces VF.
- Have available at bedside:
Symptomatic tachycardia, stable (< 150 without severe hypotension)
- Identify as 1 of 4 types of tachycardia:
- Atrial fibrillation/atrial flutter
- Narrow complex tachycardia
- Stable wide-complex tachycardia (unknown type)
- Stable monomorphic VT and/or polymorphic VT
Atrial fibrillation/atrial flutter
- Is pt clinically unstable?
- Is cardiac function impaired (EF < 40%)?
- Is Wolff-Parkinson-White present (delta wave, short P-R segment, heart rate >300)?
- Is the duration of the rhythm < 48 or >48 hrs?
- Treatment
- Treat unstable pts urgently.
- Control rate.
- Control rhythm.
- Provide anticoagulation.
- Category 1, normal EF
- Control rate.
- Beta blockers (I)
- Calcium channel blockers (I)
- Convert rhythm.
- If onset of symptoms is < 48 hrs, consider cardioversion.
- Amiodarone
- Ibutilide
- Flecainide
- Propafenone
- Procainamide
- If onset of symptoms is >48 hrs (Avoid drugs that may cardiovert patient, as patient is at risk for embolization of atrial thrombi.)
- Anticoagulate for 3 wks, then elective cardioversion & anticoagulate for additional 4 wks.
- Early cardioversion may be considered. Initiate IV heparin & perform TEE to exclude atrial clot, then cardiovert within 24 hrs & anticoagulate for 4 wks.
- If onset of symptoms is < 48 hrs, consider cardioversion.
- Category 2, EF, < 40% or CHF
- Control rate. (If AF >48 hrs, use extreme caution in pts not receiving anticoagulation.)
- Digoxin
- Diltiazem
- Amiodarone
- If onset of symptoms is < 48 hrs, consider DC cardioversion or amiodarone.
- If onset of symptoms is >48 hrs, anticoagulate for 3 wks, then elective cardioversion & anticoagulate for additional 4 wks.
- Early cardioversion may be considered. Initiate IV heparin & perform TEE to exclude atrial clot, then cardiovert within 24 hrs & anticoagulate for 4 wks.
- Control rate. (If AF >48 hrs, use extreme caution in pts not receiving anticoagulation.)
- Category 3, Wolff-Parkinson-White syndrome
- Avoid use of adenosine, beta blockers, calcium channel blockers, digoxin.
- If onset of symptoms is < 48 hrs
- Normal EF (One of the following can be used for rate control & cardioversion.)
- Amiodarone
- Flecainide (IIb)
- Procainamide (IIb)
- Propafenone (IIb)
- Sotalol (IIb)
- EF < 40% or CHF
- Amiodarone (IIb)
- Consider DC cardioversion.
- Normal EF (One of the following can be used for rate control & cardioversion.)
- If symptoms >48 hrs, anticoagulate for 3 wks, then elective cardioversion & anticoagulate for additional 4 wks.
- Early cardioversion may be considered. Initiate IV heparin & perform TEE to exclude atrial clot, then cardiovert within 24 hrs & anticoagulate for 4 wks.
Narrow-complex tachycardia (reentry SVT or PSVT, QRS >0.12 sec), EF < 40%
- No cardioversion for stable pts
- Attempt diagnostic maneuvers.
- Vagal maneuver (Valsalva, carotid sinus massage)
- Adenosine: 6 mg IV, 12 mg IV, 12 mg IV (rapid bolus technique)
- Attempt to identify rhythm.
- EF >40%
- Calcium channel blocker
- Beta blocker
- Digoxin
- Cardioversion
- Consider procainamide, amiodarone, sotalol.
- EF < 40%
- No cardioversion
- Digoxin
- Amiodarone
- Diltiazem
Wide-complex tachycardia (QRS >0.12 sec)
- EF >40%
- No cardioversion unless symptomatic
- Adenosine
- Amiodarone
- Procainamide
- Sotalol
- EF < 40%
- No cardioversion unless symptomatic
- Amiodarone
- Procainamide
- Sotalol
Ectopic or multifocal atrial tachycardia
- EF >40%
- No cardioversion unless unstable
- Calcium channel blocker
- Beta blocker
- Amiodarone
- EF < 40%
- No cardioversion unless unstable
- Amiodarone
- Diltiazem
Stable monomorphic VT: See wide-complex tachycardia above.
Stable polymorphic VT
- Is QT interval prolonged?
- Normal QT
- Correct electrolytes.
- Treat myocardial ischemia.
- EF >40%
- Beta blockers
- Lidocaine
- Amiodarone
- Procainamide
- Sotalol
- EF < 40%
- Amiodarone: 150 mg IV over 10 min, or
- Lidocaine: 0.5-0.75 mg/kg IV, then
- Synchronized cardioversion
- Switch to defibrillation if unstable.
- Prolonged QT
- Correct electrolytes.
- Consider toxic drug effect.
- Magnesium: 1-2 g IV
- Overdrive ventricular pacing
- Isoproterenol: 5 mcg/min
- Switch to defibrillation if unstable.
- Normal QT
Ongoing Assessment
- If no change in condition: repeat primary survey.
- Continue appropriate clinical & hemodynamic monitoring.
- Identify inciting events.
- Appropriate consultation
Author
- Written by Craig Manifold, MD
- Revised by Andrea Gabrielli, MD
Last updated: April 16, 2010
Citation
"ACLS Algorithms." Pocket ICU Management, PocketMedicine.com, Inc, 2010. Anesthesia Central, anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534041/all/ACLS_Algorithms.
ACLS Algorithms. Pocket ICU Management. PocketMedicine.com, Inc; 2010. https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534041/all/ACLS_Algorithms. Accessed December 1, 2024.
ACLS Algorithms. (2010). In Pocket ICU Management. PocketMedicine.com, Inc. https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534041/all/ACLS_Algorithms
ACLS Algorithms [Internet]. In: Pocket ICU Management. PocketMedicine.com, Inc; 2010. [cited 2024 December 01]. Available from: https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534041/all/ACLS_Algorithms.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC
T1 - ACLS Algorithms
ID - 534041
Y1 - 2010/04/16/
BT - Pocket ICU Management
UR - https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534041/all/ACLS_Algorithms
PB - PocketMedicine.com, Inc
DB - Anesthesia Central
DP - Unbound Medicine
ER -