ACLS

ALGORITHMS
 Acute Pulmonary Edema / Hypotension / Shock Algorithm
Clinical signs of hypoperfusion, congestive
heart failure, acute pulmonary edema
Assess ABCs Assess vitals
Secure airway Review history
Administer O2 Perform physical exam Figure 8
Start IV 12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff

What is the nature of the problem?

Volume problem
Includes PVR problems Pump Problem Rate Problem

Administer What is the BP ?

Fluids
Blood transfusions Too Slow Too Fast
Cause-specific interventions Go to Fig 5 Go to Fig 6
Consider vasopressors

Systolic BP Systolic BP Systolic BP

Systolic BP
< 70 70 - 100 mmHg 70 - 100 mmHg
> 100 mmHg
Signs of shock Signs of shock No Signs of shock
 Bradycardia Algorithm
(Patient is not in Cardiac Arrest)
Assess ABCs Assess vitals
Secure airway Review history
Administer O2 Perform physical exam
Start IV 12 lead ECG, chest x-ray Figure 5
Attach monitor, pulse oximetry and B/P Cuff

Bradycardia, either absolute

(<60 BPM) or relative

Serious signs and symptoms?a,b

Yes
No
Type II second-degree AV heart block
or
Third-degree AV heart Block?e Intervention sequence
Atropine 0.5 - 1.0 mcg,d (I and IIa)
No Yes
TCP, if available (I)
Dopamine 5 - 20 mcg/kg/min (IIb)
Prepare for transvenous pacer
Observe Use TCP as a bridge device
Epinephrine 1 - 10 mcg/min (IIb)
Norepinephrine 0.5 30 mcg/min (IIb)
 Tachycardia Algorithm
(Patient is not in Cardiac Arrest)
Assess ABCs Assess vitals
Secure airway Review history Figure 6
Administer O2 Perform physical exam
Start IV 12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff

If ventricular rate > 150 BPM

Yes Prepare for cardioversion
Unstable, with serious signs or symptoms?a May give brief trial of Rx
Immediate cardioversion is seldom
No needed for heart rates < 150 BPM

Atrial Fibrillation Paroxysmal Wide-complex Ventricular

Atrial Flutter Supraventricular tachycardia of Tachycardia (VT)
Tachycardia uncertain type
(PSVT)
 Pulseless Electrical Activity (PEA) Algorithm
(Electromechanical Dissociation [EMD]) Figure 3
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 CO2,
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
 Asystole Treatment Algorithm

Continue CPR Consider possible causes

Intubate at once Hypoxia Pre-existing acidosis
Obtain IV Access Hyperkalemia Drug Overdose
Confirm asystole in more than 1 lead Hypokalemia Hypothermia

Consider immediate
transcutaneous pacing (TCP)a
Figure 4
Epinephrine 1mg IV push,b,c
repeat q 3 - 5 min

Atropine 1 mg IV push
repeat q 3 - 5 min up to a total
of 0.03 - 0.04 mg/kgd,e

Consider termination of efforts

 Ventricular Fibrillation (VF)
Figure 2
&
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

PEA Asystole
VF/VT ROSC
Go to Fig 3 Go to Fig 4
 VF & Pulseless VT Figure 2

Continue CPR
Intubate / IV Access

Epinephrine c,d
1 mg/IV
2 mg/ETT
q 3 - 5 min

Defibrillate 360 J
within 30 - 60 sec

Administer Rx Class IIa

probable benefit f, g
Defibrillate 360 J,
30 - 60 sec after Rx