Using the BLS Healthcare Provider Algorithm for Managing VF and Pulseless VT

The BLS (basic life support) Primary Survey is used in all cases of cardiac arrest. For any
emergency, you first see if the patient is responsive, call EMS, and find an AED. For this case,
you assess a person without a pulse; you do not have an emergency care team to work with you.

Initial Assessment:

Make sure the scene is safe.

Tap shoulder and ask, "Are you all right?"

If the patient does not respond, call for help. Activate EMS

Get the automated external defibrillator (AED) or send someone for it, if someone is
available.

Perform the ABCDs in the primary survey:

Breathing

Use a barrier device if you have one.

Give each breath over 1 second.

Ventilate the patient once every 6 seconds or 10 times per minute.

Airway

Watch for the patient's chest to rise and fall. Assess the patient for NORMAL breathing.

Circulation

Check the patient's carotid pulse (take at least 5 seconds but not more than 10 seconds). No
definite pulse? Start cycles of 30 chest compressions and 2 breaths until the AED arrives.

Push hard and fast (100-120/min) and release completely.

Perform compressions at a depth of 2 inches to 2.4 inches (5-6cm).

Let the chest to completely recoil.

Minimize interruptions to less than 10 seconds.

Defibrillation using and AED

After the AED arrives, attach AED pads to the patient's chest (see AED section for details). Turn
on the AED. Follow prompts.

Is the rhythm shockable?

If the AED advises a shock, make sure bystanders or other helpers stay clear.

Give one shock.

Resume CPR immediately for 5 cycles (approximately 2 minutes). The AED will advise you
when to stop so it can analyze the rhythm. Deliver a shock if instructed to do so. Repeat cycle of
CPR. If rhythm is not shockable, resume CPR immediately for 5 cycles. Check rhythm every 5
cycles. Continue until ALS providers take over or the patient starts to move.

Unclear if the patient has a pulse?

Begin CPR immediately. Do not waste time trying to be certain about a pulse. It is better to begin
CPR that is unnecessary than to neglect compressions when they are needed. Do compressions
on a patient with a pulse is not harmful. However, delaying CPR for a pulseless patient reduces
the patient's chances of being successfully resuscitated.

Using the Pulseless Arrest Algorithm for Managing VF and Pulseless VT

The ACLS Pulseless Arrest Algorithm is the most important algorithm to know when
resuscitating adults. The algorithm steps through the assessment and management of a patient
with no pulse who does not respond to the interventions of the primary survey, including an
initial shock from an automated external defibrillator (AED). Pulseless VT is included in the
algorithm with VF. For treatment purposes, pulseless VT is treated the same as ventricular
fibrillation

The Pulseless Arrest Algorithm picks up after the primary survey has already been
conducted:

The emergency response system has been activated

CPR is being performed

An AED has been attached

 The first shock has been given

Steps

Maintain CPR. Interrupt chest compressions only for ventilation, rhythm checks, and actual
shock delivery. CPR should never be interrupted for more than 10 seconds. Remind team
members that they can prepare the drugs used ahead of time and minimize patient's time without
CPR.

1. Begin 5 cycles of CPR (approximately 2 minutes) immediately after the first shock. Each
cycle contains 30 chest compressions followed by 2 breaths.

2. Attach the patient to the monitor/defibrillator and analyze the patients rhythm.

3. Check the patient's rhythm in less than 10 seconds.

Rhythm Condition Action

If non-shockable AND QRS complexes appear

Check for a pulse
rhythm is present regular and narrow

If non-shockable Follow treatment for PEA or

WITH no pulse
rhythm is present asystole

If a shockable rhythm Continue CPR while

WITHOUT a pulse
is present defibrillator is charging

1. Continue CPR until the defibrillator has been charged.

o Turn oxygen away from the patient's chest OR turn it off.

o Make sure the source of oxygen is removed from the patient when you clear to
shock.

o Check to see that no caregivers are touching the patient.

o Shock. If using biphasic, use manufacturer recommended dosage.

Press the shock button.

 2. Immediately resume CPR for 5 cycles.

3. If IV/IO is available, administer Epinephrine 1mg IV/IO during the CPR cycle (see drug
administration in PDF file on right).

4. Check rhythm in less than 10 seconds.

5. If a shockable rhythm is present, give 1 shock.

o Continue CPR while the defibrillator is charging.

o Clear the patient for shock .

o Deliver the shock.

o Resume CPR immediately after shock, 5 cycles.

Following the sequence in the algorithm is the best scientific approach to restore spontaneous
circulation.
Using the ACLS Bradycardia Algorithm for Managing Bradycardia

The ACLS Bradycardia Algorithm outlines the steps for assessing and managing a patient who
presents with symptomatic bradycardia. It begins with the decision that the patient's heart rate is
< 60 bpm and symptomatic.

Steps

1. Decision: Heart rate is < 60 bpm and is symptomatic.

2. Assess and manage the patient using the primary and secondary surveys:

o Maintain patent airway.

o Assist breathing as needed.

o Give oxygen if oxygen saturation is less than 94% or the patient is short of breath

o Monitor blood pressure and heart rate.

o Obtain a 12-lead ECG.

o Review patient's rhythm.

o Establish IV access.

o Take a problem-focused history and physical exam.

o Search for and treat possible contributing factors.

3. Answer two questions to help you decide if the patient's signs and symptoms of poor
perfusion are caused by the bradycardia (see Figure 2).

o Are the signs or symptoms serious, such as hypotension, pulmonary congestion,

dizziness, shock, ongoing chest pain, shortness of breath, congestive heart failure,
weakness or fatigue, or acute altered mental status?

o Are the signs and symptoms related to the slow heart rate?

4. There may be another reason for the patients symptoms other than the slow heart rate.

5. Decide whether the patient has adequate or poor perfusion, since the treatment sequence
is determined by the severity of the patient's clinical presentation.
 o If perfusion is adequate, monitor and observe the patient.

o If perfusion is poor, move quickly through the following actions:

Prepare for transcutaneous pacing. Do not delay pacing. If no IV is

present pacing can be first.

Consider administering atropine 0.5 mg IV if IV access is available Repeat

every 3 to 5 minutes up to 3mg or 6 doses.

If the atropine is ineffective, begin pacing.

Consider epinephrine or dopamine while waiting for the pacer or if pacing

is ineffective.

Epinephrine 2 to 10 g/min

Dopamine 2 to 10 g/kg per minute

Progress quickly through these actions as the patient could be in pre-cardiac arrest and need
multiple interventions done in rapid succession: pacing, IV atropine, and infusion of dopamine or
epinephrine.
Using the ACLS Tachycardia Algorithm for Managing Unstable Tachycardia

Two keys to managing patients with unstable tachycardia are, first, quickly recognizing that the
patient has significant symptoms and is unstable, and second, quickly recognizing that the
patient's signs and symptoms are caused by the tachycardia. You need to decide if the tachycardia
is producing the hemodynamic instability and serious signs and symptoms or if the signs and
symptoms are producing the tachycardiafor example, the pain and distress of an acute MI
could be causing the tachycardia. Making this decision can be difficult. Generally, a heart rate
between 100 bpm and approximately 150 bpm is usually caused by an underlying process that is
represented as sinus tachycardia (see Stable Tachycardia module for more information on sinus
tachycardia). Heart rates > 150 bpm may be symptomatic. The higher the rate, the more likely
the symptoms are a result of the tachycardia. Underlying heart disease or other problems can
cause symptoms at lower heart rates. Keep in mind the following considerations:

If the patient is seriously ill or has cardiovascular disease, the patient may have
symptoms at lower rates

If the patient's heart rate is above 150 bpm and the patient is unstable (has symptoms),
cardioversion is often required.

Sinus tachycardia is always a compensatory response to an underlying condition that

creates a need for increased cardiac output. Sinus tachycardia does not respond to
cardioversion, and a shock may actually increase the patient's heart rate. The treatment
for sinus tachycardia is aimed at fixing the underlying cause, such as relieving pain,
replacing volume, or relieving axiety.

Overview

The ACLS Tachycardia Algorithm is organized around the following questions:

1. Is the patient stable or unstable?

2. Is the QRS wide or narrow?

3. Is the ventricular rhythm regular or irregular?

Steps

Does the patient have a pulse? If no, the patients rhythm is PEA and should be treated as
such.

If yes: Assess the patient using the primary and secondary surveys:

1. Check airway, breathing, and circulation.

 2. Give oxygen if the oxygen saturation is less than 94% or the patient is short of breath.

3. Perform a 12 Lead ECG if the patient is stable.

4. Identify rhythm.

5. Check blood pressure.

6. Identify and treat reversible causes if the rhythm is sinus tachycardia.

Is the patient stable?

Look for altered mental status, ongoing chest pain, hypotension, or other signs of shock.

Remember: Rate-related symptoms are uncommon if heart rate is less than 150 bpm.

If the signs and symptoms continue after you have given oxygen and supported the airway and
circulation AND if significant symptoms are due to the tachycardia, then the tachycardia is
UNSTABLE and immediate cardioversion is indicated.

If you determine that the patient has an unstable tachycardia, perform immediate synchronized
cardioversion. This is not a decision to take lightly as it carries with it a significant risk of stroke.

1. Start an IV.

2. Give sedation if the patient is conscious.

3. Do not delay cardioversion.

4. Consider expert consultation.

If you determine that the patient has a stable tachycardia, start an IV and obtain a 12-lead ECG

For a patient with a stable tachycardia, decide if the QRS complex is wide or narrow and if the
rhythm is regular.

Patient has Treatment

Narrow (< 0.12 sec) QRS complex Try vagal maneuvers

Regular rhythm Give adenosine 6 mg rapid IV push

 Repeat 12 mg dose once if necessary

Does the patient's rhythm convert? If it does, the rhythm was atrial in origin. The conversion of a
rhythm by Adenosine is considered diagnostic of atrial arrhythmia. At this point you watch for a
recurrence. If the tachycardia resumes, treat with adenosine or longer-acting AV nodal blocking
agents, such as diltiazem or beta-blockers.

Patient has Treatment

Narrow (< 0.12

Consider expert consultation
sec) QRS complex

Control patient's rate with diltiazem or beta-blockers. Use beta-

Irregular rhythm blockers with caution for patients with pulmonary disease or
congestive heart failure.

If the rhythm pattern is irregular narrow-complex tachycardia, it is probably atrial fibrillation,

possible atrial flutter, or multi-focal atrial tachycardia.

Patient has Treatment

Wide (>0.12 sec)

Expert consultation is advised.
QRS complex

Regular rhythm Expert consultation advised.

Amiodarone 150 mg IV over 10 min; repeat as needed to

If patient is in
maximum dose of 2.2 g in 24 hours Prepare for elective
ventricular
synchronized cardioversion. The half life of Amiodarone is very
tachycardia or
long. If possible consult a Cardiologist before using in a stable
uncertain rhythm
patient. Another choice would be to use Procainamide.
If patient is in SVT Adenosine 6 mg rapid IV push If no conversion, give 12 mg
with aberrancy rapid IV push; may repeat 12 mg dose once

Patient has Treatment

Wide (> 0.12) QRS complex

Irregular rhythm Seek expert consultation

If pre-excited atrial fibrillation Avoid AV nodal blocking agents such as adenosine,

(AF + WPW) digoxin, diltiazem, verapamil

Consider amiodarone 150 mg IV over 10 min

If recurrent polymorphic VT Seek expert consultation

If torsades de pointes Seek expert consultation

You may not always be able to tell from the ECG whether the rhythm is ventricular or
supraventricular. Most wide-complex tachycardias originate in the ventricles (particularly if the
patient is older or has underlying heart disease). If the patient does not have a pulse, treat the
rhythm as ventricular fibrillation and follow the Pulseless Arrest Algorithm.

If the patient is unstable and has a wide-complex tachycardia, assume the rhythm is VT until you
can prove otherwise.
Using the ACLS Tachycardia Algorithm for Managing Stable Tachycardia

The key to managing a patient with any tachycardia is to check if pulses are present, decide if the
patient is stable or unstable, and then treat the patient based on the patient's condition and
rhythm. If the patient does not have a pulse, follow the ACLS Pulseless Arrest Algorithm. If the
patient has a pulse, manage the patient using the ACLS Tachycardia Algorithm.

Definition of Stable Tachycardia

For a diagnosis of stable tachycardia, the patient meets the following criteria:

The patient's heart rate is greater than 100 bpm.

The patient does not have any serious signs or symptoms as a result of the increased heart
rate.

Overview

Find out if significant symptoms are present. Evaluate the symptoms and decide if they are
caused by the tachycardia or other systemic conditions. Use these questions to guide your
assessment:

Does the patient have symptoms?

Is the tachycardia causing the symptoms?

Is the patient stable or unstable?

Is the QRS complex narrow or wide?

Is the rhythm regular or irregular?

Is the rhythm sinus tachycardia?

Guidelines

Situation Assessment and Actions

Patient has significant signs or symptoms of
The tachycardia is unstable. Immediate
tachycardia AND they are being caused by
cardioversion is indicated.
the arrhythmia.

Follow the Pulseless Arrest Algorithm.

Patient has a pulseless ventricular
Deliver unsynchronized high-energy
tachycardia.
shocks.

Treat the rhythm as ventricular

Patient has polymorphic ventricular
fibrillation. Deliver unsynchronized
tachycardia AND the patient is unstable.
high-energy shocks.

Steps for Managing Stable Tachycardia

Does the patient have a pulse?

Yes, the patient has a pulse. Complete the following:

1. Assess the patient using the primary and secondary surveys.

2. Check the airway, breathing, and circulation

3. Give oxygen and monitor oxygen saturation.

4. Get an ECG.

5. Identify rhythm.

6. Check blood pressure.

7. Identify and treat reversible causes.

Is the patient stable?

Look for altered mental status, ongoing chest pain, hypotension, or other signs of shock.

Remember: Rate-related symptoms are uncommon if heart rate is < 150 bpm.

Yes, the patient is stable. Take the following actions:

1. Start an IV.

2. Obtain a 12-lead ECG or rhythm strip.

Is the QRS complex wide or narrow?

Patient Treatment

The patient's QRS is Try vagal maneuvers. Give adenosine 6 mg rapid IV push. If
narrow and rhythm is patient does not convert, give adenosine 12 mg rapid IV push.
regular. May repeat 12 mg dose of adenosine once.

Does the patient's rhythm convert? If it does, it was probably reentry supraventricular
tachycardia. At this point you watch for a recurrence. If the tachycardia resumes, treat with
adenosine or longer-acting AV nodal blocking agents, such as diltiazem or beta-blockers.

Patient Treatment

The patient's QRS is

Consider an expert consultation.
narrow (< 0.12 sec).

Control patient's rate with diltiazem or beta-blockers. Use beta-

The patient's rhythm
blockers with caution for patients with pulmonary disease or
is irregular.
congestive heart failure.

If the rhythm pattern is irregular narrow-complex tachycardia, it is probably atrial fibrillation,

possible atrial flutter, or multi-focal atrial tachycardia.

Patient Treatment
Patient's rhythm has wide (> 0.12
sec) QRS complex AND Patient's Expert consultation is advised.
rhythm is regular.

Amiodarone 150 mg IV over 10 min; repeat as

Patient is in ventricular tachycardia
needed to maximum dose of 2.2 g in 24 hours.
or uncertain rhythm.
Prepare for elective synchronized cardioversion.

Adenosine 6 mg rapid IV push If no conversion,

Patient is in supraventricular
give adenosine 12 mg rapid IV push; may repeat
tachycardia with aberrancy.
12 mg dose once.

Patient's rhythm has wide (> 0.12)

QRS complex AND Patient's Seek expert consultation.
rhythm is irregular.

If pre-excited atrial fibrillation

Avoid AV nodal blocking agents such as
(Atrial Fibrillation in Wolff-
adenosine, digoxin, diltiazem, verapamil.
Parkinson-White Syndrome)

Consider amiodarone 150 mg IV over 10 min.

Patient has recurrent polymorphic

Seek expert consultation,
VT

If patient has torsades de pointes Give magnesium (load with 1-2 g over 5-60 min;
rhythm on ECG then infuse.

Caution: If the tachycardia has a wide-complex QRS and is stable, consult with an expert.
Management and treatment for a stable tachycardia with a wide QRS complex and either a
regular or irregular rhythm should be done in the hospital setting with expert consultation
available. Management requires advanced knowledge of ECG and rhythm interpretation and
anti-arrhythmic therapy.

Considerations:
 You may not be able to distinguish between a supraventricular wide-complex rhythm and
a ventricular wide-complex rhythm. Most wide-complex tachycardias originate in the
ventricles.

If the patient becomes unstable, proceed immediately to treatment. Do not delay while
you try to analyze the rhythm.

If the patient becomes unstable, proceed immediately to treatment. Do not delay while
you try to analyze the rhythm.

Using the ACLS Tachycardia Algorithm for Managing Stable Tachycardia

The key to managing a patient with any tachycardia is to check if pulses are present, decide if the
patient is stable or unstable, and then treat the patient based on the patient's condition and
rhythm. If the patient does not have a pulse, follow the ACLS Pulseless Arrest Algorithm. If the
patient has a pulse, manage the patient using the ACLS Tachycardia Algorithm.

Definition of Stable Tachycardia

For a diagnosis of stable tachycardia, the patient meets the following criteria:

The patient's heart rate is greater than 100 bpm.

The patient does not have any serious signs or symptoms as a result of the increased heart
rate.

The patient has an underlying cardiac electrical abnormality that is generating the
arrhythmia.

Overview

Find out if significant symptoms are present. Evaluate the symptoms and decide if they are
caused by the tachycardia or other systemic conditions. Use these questions to guide your
assessment:

Does the patient have symptoms?

Is the tachycardia causing the symptoms?

 Is the patient stable or unstable?

Is the QRS complex narrow or wide?

Is the rhythm regular or irregular?

Is the rhythm sinus tachycardia?

Guidelines

Situation Assessment and Actions

Patient has significant signs or symptoms of
The tachycardia is unstable. Immediate
tachycardia AND they are being caused by
cardioversion is indicated.
the arrhythmia.
Follow the Pulseless Arrest Algorithm.
Patient has a pulseless ventricular
Deliver unsynchronized high-energy
tachycardia.
shocks.
Treat the rhythm as ventricular
Patient has polymorphic ventricular
fibrillation. Deliver unsynchronized
tachycardia AND the patient is unstable.
high-energy shocks.

Steps for Managing Stable Tachycardia

Does the patient have a pulse?

Yes, the patient has a pulse. Complete the following:

1. Assess the patient using the primary and secondary surveys.

2. Check the airway, breathing, and circulation

3. Give oxygen and monitor oxygen saturation.

4. Get an ECG.

5. Identify rhythm.

6. Check blood pressure.

7. Identify and treat reversible causes.

Is the patient stable?

Look for altered mental status, ongoing chest pain, hypotension, or other signs of shock.

Remember:Rate-related symptoms are uncommon if heart rate is < 150 bpm.

Yes, the patient is stable.Take the following actions:

1. Start an IV.

2. Obtain a 12-lead ECG or rhythm strip.

Is the QRS complex wide or narrow?

Patient Treatment
The patient's QRS is Try vagal maneuvers. Give adenosine 6 mg rapid IV push. If
narrow and rhythm is patient does not convert, give adenosine 12 mg rapid IV push.
regular. May repeat 12 mg dose of adenosine once.

Does the patient's rhythm convert? If it does, it was probably reentry supraventricular
tachycardia. At this point you watch for a recurrence. If the tachycardia resumes, treat with
adenosine or longer-acting AV nodal blocking agents, such as diltiazem or beta-blockers.

Patient Treatment
The patient's QRS is
Consider an expert consultation.
narrow (< 0.12 sec).
Control patient's rate with diltiazem or beta-blockers. Use beta-
The patient's rhythm
blockers with caution for patients with pulmonary disease or
is irregular.
congestive heart failure.

If the rhythm pattern is irregular narrow-complex tachycardia, it is probably atrial fibrillation,

possible atrial flutter, or multi-focal atrial tachycardia.

Patient Treatment
Patient's rhythm has wide (> 0.12
sec) QRS complex AND Patient's Expert consultation is advised.
rhythm is regular.
 Amiodarone 150 mg IV over 10 min; repeat as
Patient is in ventricular tachycardia
needed to maximum dose of 2.2 g in 24 hours.
or uncertain rhythm.
Prepare for elective synchronized cardioversion.
Adenosine 6 mg rapid IV push If no conversion,
Patient is in supraventricular
give adenosine 12 mg rapid IV push; may repeat
tachycardia with aberrancy.
12 mg dose once.
Patient's rhythm has wide (> 0.12)
QRS complex AND Patient's Seek expert consultation.
rhythm is irregular.
If pre-excited atrial fibrillation
Avoid AV nodal blocking agents such as
(Atrial Fibrillation in Wolff-
adenosine, digoxin, diltiazem, verapamil.
Parkinson-White Syndrome)
Consider amiodarone 150 mg IV over 10 min.
Patient has recurrent polymorphic
Seek expert consultation,
VT
If patient has torsades de pointes Give magnesium (load with 1-2 g over 5-60 min;
rhythm on ECG then infuse.

Caution: If the tachycardia has a wide-complex QRS and is stable, consult with an expert.
Management and treatment for a stable tachycardia with a wide QRS complex and either a
regular or irregular rhythm should be done in the hospital setting with expert consultation
available. Management requires advanced knowledge of ECG and rhythm interpretation and
anti-arrhythmic therapy.

Considerations:

You may not be able to distinguish between a supraventricular wide-complex rhythm and
a ventricular wide-complex rhythm. Most wide-complex tachycardias originate in the
ventricles.

If the patient becomes unstable, proceed immediately to treatment. Do not delay while
you try to analyze the rhythm.

If the patient becomes unstable, proceed immediately to treatment. Do not delay while
you try to analyze the rhythm.