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
      • Asystole or PEA
        • CPR
        • Pressors
        • Atropine
        • Differential diagnosis
        • CPR

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.

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.
  • 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.
  • 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.
    • 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.

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

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Last updated: April 16, 2010

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