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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
Bradycardia Tachycardia
Go to Fig 3 Go to Fig 4
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
Establish IV access
Obtain 12-lead ECG
Is QRS narrow (<0.12 sec)?
Narrow
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 Develops high or intermediate risk criteria
Start adjunctive treatments as Nitroglycerine (refractory chest pain, pulmonary edema,
indicated beta-Adrenergic receptor blockers mitral regurgitation, hypotension, etc)
Do not delay reperfusion Clopidogrel OR
beta-Adrenergic receptor blockers Heparin (unfractionated or low molecular weight Troponin-positive
Clopidogrel heparin)
Heparin (unfractionated or low Glycoprotein IIb/IIIa inhibitor
molecular weight heparin)
Consider admission to ED chest pain unit or
to monitored bed in ED
Follow:
$12 hours Admit to monitored bed Serial cardiac markers (including troponin)
Time from onset of Assess risk status
symptoms #12 hours? Repeat ECG/continuous ST segment monitoring
Consider stress test
#12 hours
High-risk patient
Refractory ischemic chest pain Develops high or intermediate risk
Reperfusion strategy
Recurrent/persistent ST deviation criteria (refractory chest pain,
Reperfusion goals:
Ventricular tachycardia pulmonary edema, mitral regurgitation,
Door-to-balloon inflation (PCI) goal of 90
Hemodynamic instability hypotension, etc)
min
Signs of pump failure OR
Door-to-needle (fibrinolysis) goal of 30 min
Early invasie strategy, including catheterization and Troponin-positive
Continue adjunctive therapies and:
revascularization for shock within 48 hours of an AMI
ACE inhibitors/angiotensin receptor
Continue ASA, heparin, and other therapies as
blocker within 24 hours of symptom onset
indicated.
HMGCoA reductase inhibitor (statin) If no evidence of ischemia or
ACE inhibitor/ARB
HMGCoA reductase inhibitor (statin) infarction, can discharge with
follow-up