Advanced Cardiac Life Support

Basic Life Support Algorithm

Assess Responsiveness

No movement or response
Call for code team and Defibrillator
Open the airway, look, listen and feel for
breathing)

If Not Breathing,
give 2 breaths that make chest rise
Check pulse

PULSE NO PULSE

Give oxygen by bag mask. One breath Initiate CPR at cycles of

every 5 to 6 seconds. 30 compressions and 2
Recheck pulse every 2 minutes breaths until defibrillator
Secure IV access arrives.
Determine probable etiology of arrest
based on history, physical exam,
cardiac monitor, vital signs, and 12
lead ECG. Defibrillator arrives.
Check Rhythm
Shockable rhythm?
Hypotension/shock,
acute pulmonary Not Shockable
edema. shockable
Go to fig 5

Asystole or Pulseless Ventricular

Electrical Activity Tachycardia or
Arrhythmia Go to Fig 2 Ventricular
Fibrillation
Go to Fig 2

Bradycardia Tachycardia
Go to Fig 3 Go to Fig 4

Fig 1 - Basic Life Support Algorithm

 PULSELESS ARREST

1
Assess Airway, Breathing, Circulation, Differential Diagnosis; call for help
Give CPR and oxygen
Attach monitor/defibrillator
Shockable 2 Check rhythm Not Shockable
Shockable rhythm?
3 9
Ventricular Fibrillation or Asystole or Pulseless
Ventricular Tachycardia Electrical Activity

4 10
Give 1 shock Resume CPR for 5 cycles
Manual biphasic: 120-200 J When IV/IO available, give
Monophasic: 360 J vasopressor
Resume CPR Epinephrine 1 mg IV/IO
or
Give 5 cycles of CPR May give 1 dose of vasopressin 40 U
5 IV/IO to replace first or second
No dose of epinephrine
Check rhythm
Consider atropine 1 mg IV/IO for
Shockable rhythm?
asystole or slow PEA rate. Repeat
every 3 to 5 min, up to 3 doses
6 Shockable
Continue CPR
Give 5 cycles
Give 1 shock
of CPR
Manual biphasic: same as first
shock or higher dose
Monophasic: 360 J Check rhythm
Resume CPR Shockable rhythm?
Give vasopressor during CPR
Epinephrine 1 mg IV/IO. Repeat
every 3 to 5 min or
May give 1 dose of vasopressin 40
U IV/IO to replace first or second
dose of epinephrine
Give 5 cycles of CPR If asystole, go to Box 10
7 If electrical activity, check
pulse. If no pulse, go to No Shockable
Check rhythm No box 10 Go to
Shockable rhythm? Ifpulse present, begin Box 4
postresusitation care
Shockable
8
Continue CPR
Give 1 shock
Manual biphasic: Same as first shock or higher dose.
Monophasic: 360 J
Resume CPR
Consider antiarrhythmicsduring CPR:
Amiodarone 300 mg IV/IO once, then 150 mg IV/IO once or
Lidocaine 1-1.5 mg/kg first dose, then 0.5 to 0.75 mg/kg IV/IO, max 3
doses or 3 mg/kg
Consider magnesium, loading dose 1 to 2 g IV/IO for torsades de pointes
After 5 cycles of CPR, go to box 5 above

Fig 2 - Pulseless Arrest Algorithm

 BRADYCARDIA

Bradycardia (<60 beats/min) and inadequate for

clinical condition

Maintain patent Airway, assist Secure IV access

Breathing as needed Review history
Give oxygen
Monitor ECG, pulse oximeter and
blood pressure

Signs or symptoms of Poor Perfusion caused by bradycardia?

(eg, onfusion, delirium, lethargy, chest pain, hypotension or other signs of shock)

Adequate Poor Perfusion

Perfusion

Observe and Monitor • Initiate transcutanous pacing for high-

Reminders
• If pulseless arrest develops,
go to Pulseless Arrest
Algorithm
• Search for and treat possible
contributing factors:
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo/hyperkalemia
Hypoglycemia
Hypothermia
Toxins
Tamponade, cardiac
Tension pneumothorax
Thrombosis (coronary or
pulmonary)
Trauma (hypovolemia,
increased ICP)
degree block (type II second or 3rd degree
heart block, wide complex escape beats,
MI/ischemia, denervated heart
(transplant),new bundle branch block)
• Consider atropine 0.5 mg IV, repeat q5min to
a total dose of 3 mg. Initiate pacing if
bradycardia continues.
• Consider epinephrine 2-10 mcg/min IV
infusion or dopamine 2-10 mcg/kg per min IV
infusion while awaiting pacer or if pacing
ineffective
Initiate transvenous pacing
Treat contributing causes
Obtain cardiology consultation

Fig 3 - Bradycardia Algorithm (with patient not in cardiac arrest).

 TACHYCARDIA With Pulses

Assess and support Airway, Breathing, Circulation

Give 100% oxygen
Monitor ECG and identify rhythm. Monitor oximeter, blood pressure
Identify and treat reversible causes
Review history and examine patient

IMMEDIATE SYNCHRONIZED CARDIOVERSION

Is the patient stable?
Unstable Establish IV access and give midazolam (Versed) 2-5 mg IVP if patient is
Unstable includes, hypotension, heart failure, chest pain,
conscious; do not delay cardioversion
decreased mental status, or other signs of shock Cardiovert atrial flutter with 50 J, paroxysmal supraventricular tachycardia 50
J, atrial fibrillation 100 J, monomorphic ventricular tachycardia100 J.
Polymorphic V tachycardia 360 J unsynchronized.
Stable If pulseless arrests develops, see Pulseless Arrest Algorithm, figure 2.

Establish IV access
Obtain 12-lead ECG
Is QRS narrow (<0.12 sec)?

Wide ($0.12 sec)

Narrow

NARROW QRS: WIDE QRS:

Is Rhythm Regular? Is Rhythm Regular?

Regular Irregular Regular Irregular

 Irregular Narrow-Complex If ventrucular tachycardia or If atrial fibrillation with
Attempt vagal maneuvers uncertain rhythm aberrrancy
Give adenosine 6 mg rapid IV push. Tachycardia
Probable atrial fibrillation or possible Amiodarone 150 mg IV over 10 min. See Irregular Narrow-Complex
If no conversion, give 12 mg Repeat as needed to max 2.2 g/24 Tachycardia
rapid IV push; may repeat 12 mg atrial flutter or multifocal atrial
tachycardia hours If pre-excited atrial fibrillation (AF
dose once Prepare for elective synchronized + WPW)
Control rate (eg, diltiazem, beta-
blockers) cardioversion Avoid AV nodal blocking agents (eg,
If SVT with aberrancy adenosine, digoxin, diltiazem,
Give adenosine 6 mg, rapid IV push verapamil)
(may repeat 12 mg once) Consider amiodarone150 mg IV
over 10 min
If recurrent polymorphic VT, seek
Does rhythm cardiology consultation
convert? If torsades de pointes, give
magnesium load of 1-2 g over 5-
Converts Does Not Convert 60 min, then infuse 3-10 mg/min
for 7-48h

Treat contributing factors:

If rhythm converts, probable reentry If rhythm does NOT convert, Hypovolemia Toxins
supraventricular tachycardia: possible atrial flutter, Hypoxia Tamponade, cardiac
Observe for recurrence ectopic atrial tachycardia, Hydrogen ion (acidosis) Tension pneumothorax
Treat recurrence with adenosine or or junctional tachycardia: Hypo/hyperkalemia Thrombosis (coronary or
longer-acting AV nodal blocking Control rate (eg diltiazem, Hypoglycemia pulmonary)
agents (eg, diltiazem, beta- beta-blockers) Hypothermia Trauma (hypovolemia,
blockers) Treat underlying cause increased ICP)

Figure 4 Tachycardia With Pulses

 Acute Coronary Syndromes Algorithm

Chest discomfort suggestive of ischemia

Immediate Emergency Department Assessment Immediate Emergency Department treatment

Check vital signs; evaluate oxygen saturation Oxygen at 4 L/min; maintain O2 sat >90%
Establish IV access Aspirin 160-325 mg (if not given by EMS)
Obtain/review 12-lead ECG Nitroglycerine sublingual spray, or IV
Perform brief, targeted history, physical exam Morphine IV if pain not relieved by nitroglycerine
Complete fibrinolytic checklist; check contraindications
Obtain initial cardiac marker levels, initial electrolyte and
coagulation studies
Obtain portable chest x-ray

Review initial 12-lead ECG

ST elevation or new or presumably new LBBB; ST depression or dynamic T-wave inversion; strongly Normal or nondiagnostic changes in ST
strongly suspicious for injury suspicious for ischemia segment or T wave
ST-Elevation MI (STEMI) High-Risk Unstable Angina/ Non-ST-Elevation MI Intermediate/Low-Risk Unstable Angina
(UA/NSTEMI)

Start adjunctive treatments as
indicated
Do not delay reperfusion
beta-Adrenergic receptor blockers
Clopidogrel
Heparin (unfractionated or low
molecular weight heparin)
$12 hours
Time from onset of
symptoms #12 hours?
#12 hours
Reperfusion strategy
Reperfusion goals:
Door-to-balloon inflation (PCI) goal of 90
min
Door-to-needle (fibrinolysis) goal of 30 min
Continue adjunctive therapies and:
ACE inhibitors/angiotensin receptor
blocker within 24 hours of symptom onset
HMGCoA reductase inhibitor (statin)
Figure 6 - Acute Coronary Syndromes Algorithm
Start adjunctive treatments as indicated Develops high or intermediate risk criteria
Nitroglycerine (refractory chest pain, pulmonary edema,
beta-Adrenergic receptor blockers mitral regurgitation, hypotension, etc)
Clopidogrel OR
Heparin (unfractionated or low molecular weight Troponin-positive
heparin)
Glycoprotein IIb/IIIa inhibitor
Consider admission to ED chest pain unit or
to monitored bed in ED
Follow:
Admit to monitored bed Serial cardiac markers (including troponin)
Assess risk status
Repeat ECG/continuous ST segment monitoring
Consider stress test
High-risk patient
Refractory ischemic chest pain Develops high or intermediate risk
Recurrent/persistent ST deviation criteria (refractory chest pain,
Ventricular tachycardia pulmonary edema, mitral regurgitation,
Hemodynamic instability hypotension, etc)
Signs of pump failure OR
Early invasie strategy, including catheterization and Troponin-positive
revascularization for shock within 48 hours of an AMI
Continue ASA, heparin, and other therapies as
indicated.
If no evidence of ischemia or
ACE inhibitor/ARB
HMGCoA reductase inhibitor (statin) infarction, can discharge with
follow-up
 HYPOTENSION,SHOCK,ANDACUTEPULMONARYEDEMA

Signs and symptoms of congestive heart failure, acute pulmonary edema.

Assess ABCD's, secure airway, administer oxygen; secure IV access. Monitor ECG, pulse oximeter,
blood pressure, order 12-lead ECG, portable chest X-ray
Check vital signs, review history, and examine patient. Determine differential diagnosis.

Determine underlying cause

Pump Failure Bradycardia or Tachycardia

Hypovolemia
Bradycardia Tachycardia
Determine blood pressure Go to Fig 3
Administer Fluids, Blood Go to Fig 4
Consider vasopressors
Apply hemostasis; treat Systolic BP >100 mm Hg
underlying problem Systolic BP Systolic BP Diastolic BP >110 mm Hg
<70 mm Hg 70-100 mm Hg and diastolic BP normal

Norepinephrine 0.5- Dobutamine 2.0-20

Dopamine 2.5-20 If ischemia and hypertension:
30 mcg/min IV or mcg/kg per min IV
mcg/kg per min IV Nitroglycerin10-20 mcg/min
Dopamine 5-20 (add norepinephrine IV, and titrate to effect and/or
mcg/kg per min if dopamine is >20 Furosemide IV 0.5-1.0 mg/kg Nitroprusside 0.1-5.0
mcg/kg per min) Morphine IV 1-3 mg mcg/kg/min IV
Nitroglycerin SL 0.4 mg tab
q3-5min x3
Oxygen
Figure 6 - Hypotension, Shock, and Acute Pulmonary Edema