ACLS

ALGORITHMS
Acute Pulmonary Edema / Hypotension / Shock Algorithm

Volume problem
Includes PVR problems
Systolic BP
< 70
Signs of shock
Administer
Fluids
Blood transfusions
Cause-specific interventions
Consider vasopressors
Too Slow
Go to Fig 5
Rate Problem Pump Problem
Systolic BP
70 - 100 mmHg
Signs of shock
Too Fast
Go to Fig 6
Systolic BP
> 100 mmHg
Systolic BP
70 - 100 mmHg
No Signs of shock
Clinical signs of hypoperfusion, congestive
heart failure, acute pulmonary edema
Assess ABCs Assess vitals
Secure airway Review history
Administer O
2
Perform physical exam
Start IV 12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff
What is the nature of the problem?
What is the BP ?
Figure 8
Bradycardia Algorithm
(Patient is not in Cardiac Arrest)
Assess ABCs Assess vitals
Secure airway Review history
Administer O
2
Perform physical exam
Start IV 12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff
Intervention sequence
Atropine 0.5 - 1.0 mcg
,d
(I and IIa)
TCP, if available (I)
Dopamine 5 - 20 mcg/kg/min (IIb)
Epinephrine 1 - 10 mcg/min (IIb)
Norepinephrine 0.5 30 mcg/min (IIb)
Bradycardia, either absolute
(<60 BPM) or relative
Type II second-degree AV heart block
or
Third-degree AV heart Block?
e

Serious signs and symptoms?
a,b

No
No Yes
Yes
Observe
Prepare for transvenous pacer
Use TCP as a bridge device
Figure 5
Tachycardia Algorithm
(Patient is not in Cardiac Arrest)
Assess ABCs Assess vitals
Secure airway Review history
Administer O
2
Perform physical exam
Start IV 12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff
If ventricular rate > 150 BPM
Prepare for cardioversion
May give brief trial of R
x

Immediate cardioversion is seldom
needed for heart rates < 150 BPM


Wide-complex
tachycardia of
uncertain type
Ventricular
Tachycardia (VT)
Paroxysmal
Supraventricular
Tachycardia
(PSVT)
Atrial Fibrillation
Atrial Flutter
Unstable, with serious signs or symptoms?
a

Yes
No
Figure 6
Pulseless Electrical Activity (PEA) Algorithm
(Electromechanical Dissociation [EMD])
Includes
Electromechanical dissociation (EMD) Postdefibrillation idioventricular rhythms
Pseudo - EMD Bradyasystolic rhythms
Idioventricular rhythms Ventricular escape rhythms
Continue CPR / Intubate at once / Obtain IV Access
Assess blood flow using Doppler ultrasound, endtidal CO
2
,
echocardiography, or arterial line
Consider possible causes
Hypovolemia (volume infusion) Drug overdoses - tricyclics, digitalis
Hypoxia (ventilation) Beta-blockers, calcium channel blockers
Cardiac tamponade (pericardiocentesis) Hyperkalemia
Tension Pneumothorax Acidosis
Hypothermia ( see hypothermia algorithm) Massive acute myocardial infarction
Massive pulmonary embolism (surgery, lysine) Massive acute MI (go to Fig 9)
Epinephrine 1 mg IV push,
a,c
repeat q 3 - 5 min
If absolute bradycardia (< 60 BPM) or relative bradycardia
give atropine 1 mg IV
Repeat q 3 -5 min to a total of 0.03 - 0.04 mg/kg
Figure 3

Asystole Treatment Algorithm

Continue CPR
Intubate at once
Obtain IV Access
Confirm asystole in more than 1 lead
Atropine 1 mg IV push
repeat q 3 - 5 min up to a total
of 0.03 - 0.04 mg/kg
d,e

Epinephrine 1mg IV push,
b,c

repeat q 3 - 5 min
Consider possible causes
Hypoxia Pre-existing acidosis
Hyperkalemia Drug Overdose
Hypokalemia Hypothermia
Consider termination of efforts
Consider immediate
transcutaneous pacing (TCP)
a

Figure 4
Ventricular Fibrillation (VF)
&
Pulseless Ventricular Tachycardia (VT)
ABCs
Perform CPR until defibrillator Arrives
VF/VT present on defibrillator
Defibrillate up to 3 times if needed for persistent VF/VT
200 J, 200 - 300 J, 360 J
Rhythm after the first 3 shocks?
b

Asystole
Go to Fig 4
PEA
Go to Fig 3
VF/VT ROSC
Figure 2
Continue CPR
Intubate / IV Access
VF & Pulseless VT
Defibrillate 360 J,
30 - 60 sec after R
x

Epinephrine
c,d

1 mg/IV
2 mg/ETT
q 3 - 5 min
Administer R
x
Class IIa
probable benefit
f, g

Defibrillate 360 J
within 30 - 60 sec
Figure 2