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ACLS

Agorithm
Cardiac Arrest Adult Cardiac
Algorithm Arrest

• Tap the patient on the


shoulder and ask, "Are
you all right?"
• If the patient does not
respond
Cardiac Arrest Adult Cardiac
Algorithm Arrest

Shout for
Help/Activate
• For witnessed arrest: EMS
Call for Help
• For unwitnessed arrest:
Give 5 Cycles of CPR
before calling for help
Cardiac Arrest Adult Cardiac
Algorithm Arrest

Shout for
Help/Activate
• Check for a pulse EMS

• begin CPR: 30:2


Start CPR
• Begin oxygen FIRST cycle
• Attach a cardiac
monitor
Cardiac Arrest Adult Cardiac
Algorithm Arrest

During CPR the rest of team Shout for


should: Help/Activate
EMS
• connect a pulse oximeter
• Connect a NIBP Start CPR
• draw venous blood, send FIRST cycle
it off for electrolytes and
glucose levels
• draw arterial blood send
it off for ABGs
Cardiac Arrest Adult Cardiac
Algorithm Arrest

Shout for
Help/Activate
• Check the patient's EMS

rhythm,
Start CPR
• Taking less than 10 FIRST cycle
seconds to assess.
• Simultaneuosly, check Check for
for Pulse Rhythm
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Pulseless Ventricular tachycardia

• Ventricular Fibrillation
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Unwitnessed arrest:
means CPR before
Give FIRST Shock
shock
• Witnessed arrest:
SHOCK FIRST!

Monophasic: 360 Joules


Biphasic: 200 Joules
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

• Charge up the Defibrillator.


• Talk aloud. "Charging, 200 Give FIRST Shock
Joules Asynchronous
shock".
• Make sure you get
everyone clear first. "I am
clear, you are clear,
everybody clear"
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

Talk aloud:
Give FIRST Shock
• “Shocking now, 200
Joules“
• "Resume CPR please“
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

• Give 5 cycles of CPR Give FIRST Shock


• Start IV/IO access,
running full
Start CPR
SECOND cycle
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

• Check the patient's Give FIRST Shock


rhythm,
• Taking less than 10
Start CPR
seconds to assess. SECOND cycle
• Simultaneuosly, check
for Pulse Check for
Rhythm
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Pulseless Ventricular tachycardia

• Ventricular Fibrillation
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Unwitnessed arrest:
means CPR before Give SECOND
shock Shock
• Witnessed arrest:
SHOCK FIRST!

Monophasic: 360 Joules


Biphasic: 200 Joules
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

• Charge up the Defibrillator.


• Talk aloud. "Charging, 220 Give SECOND
Joules Asynchronous Shock

shock".
• Make sure you get
everyone clear first. "I am
clear, you are clear,
everybody clear"
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

Talk aloud: Give SECOND


• “Shocking now, 220 Shock

Joules“
• "Resume CPR please“
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

• Give 5 cycles of CPR Give SECOND


• give Epinephrine 1mg Shock
before the next shock,
in the middle of the Start CPR
third round of CPR THIRD cycle

• Give epinephrine every


3-5 min
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Consider advanced
airway: Give SECOND
Shock
For advanced airway
continuous chest
compressions without Start CPR
pauses for breaths. Give 8 THIRD cycle
to 10 breaths per minute
and check rhythm every 2
minutes.
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

• Check the patient's


Give FIRST Shock
rhythm,
• Taking less than 10
seconds to assess. Start CPR
• Simultaneuosly, check SECOND cycle

for Pulse
Check for
Rhythm
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Pulseless Ventricular tachycardia

• Ventricular Fibrillation
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Unwitnessed arrest:
means CPR before Give THIRD
shock Shock
• Witnessed arrest:
SHOCK FIRST!

Monophasic: 360 Joules


Biphasic: 200 Joules
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

• Charge up the Defibrillator.


• Talk aloud. "Charging, 250 Give THIRD
Joules Asynchronous Shock

shock".
• Make sure you get
everyone clear first. "I am
clear, you are clear,
everybody clear"
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

Talk aloud: Give THIRD


• “Shocking now, 250 Shock

Joules“
• "Resume CPR please“
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Give 5 cycles of CPR
• give Amiodarone
Give THIRD
300mg IV before the Shock
next shock, in the
middle of the fourth Start CPR
round of CPR FOURTH cycle

• Give epinephrine every


15 min
• Second dose 150mg IV
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Treat reversible Cause:
Give THIRD
5H’s Shock
Hypovolemia
Hypoxia
Start CPR
Hydrogen Ion (acidosis) FOURTH cycle
Hypo/Hyperkalemia
Hypothermia
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT
• Treat reversible Cause:
Give THIRD
5T’s Shock
Tension pneumothorax
Tamponade, Cardiac Start CPR
Toxins FOURTH cycle
Thrombosis, Pulmonary
Thrombosis, Coronary
Shockable
Cardiac Arrest
Algorithm
VF/Pulseless VT

• Repeat Cycle Give THIRD


Shock

Start CPR
FOURTH cycle

Check for
Rhythm
Not
Cardiac Arrest Shockable
Algorithm
Asystole/PEA
• Asystole

• Pulseless Electrical Activity


Not
Cardiac Arrest Shockable
Algorithm
Asystole/PEA

• Give 5 cycles of CPR


• Start IV/IO access, Start CPR
FIRST cycle
running full
Not
Cardiac Arrest Shockable
Algorithm
Asystole/PEA
• Give 5 cycles of CPR
• give Epinephrine 1mg Start CPR
before the next shock, FIRST cycle
in the middle of the
round of CPR
• Give epinephrine every
3-5 min
Not
Cardiac Arrest Shockable
Algorithm
Asystole/PEA
• Consider advanced
airway: Start CPR
FIRST cycle
For advanced airway
continuous chest
compressions without
pauses for breaths. Give 8
to 10 breaths per minute
and check rhythm every 2
minutes.
Not
Cardiac Arrest Shockable
Algorithm
Asystole/PEA

• Check the patient's Start CPR


rhythm, FIRST cycle
• Taking less than 10
seconds to assess. Check for
• Simultaneuosly, check Rhythm

for Pulse
Not
Cardiac Arrest Shockable
Algorithm
Asystole/PEA

• Give 5 cycles of CPR


• Treat reversible causes Start CPR
FIRST cycle

5H’s
Hypovolemia Check for
Hypoxia Rhythm
Hydrogen Ion (acidosis)
Hypo/Hyperkalemia Start CPR
Hypothermia SECOND cycle
Not
Cardiac Arrest Shockable
Algorithm
Asystole/PEA
• Treat reversible Cause:
Start CPR
5T’s FIRST cycle
Tension pneumothorax
Tamponade, Cardiac Check for
Toxins Rhythm
Thrombosis, Pulmonary
Thrombosis, Coronary Start CPR
SECOND cycle
Bradycardia (with Pulse)
HR < 50/min
Algorithm

Attach:
• Oxygen by simple face
mask
• start an IV
• Pulse oximeter
• NIBP
• Draw venous blood
Bradycardia (with Pulse)
HR < 50/min
Algorithm

Stable:
• No chest pain Stable
• No SOB
• No hypotension
• No altered mental
status or any signs of
shock.
Bradycardia (with Pulse)
HR < 50/min
Algorithm

Unstable:
• Chest pain Unstable
• Shortness of breath
• Hypotension
• Altered mental status
• Shock
• Pulmonary Edema
Bradycardia (with Pulse)
HR < 50/min
Algorithm

• Atropine 0.5mg IV
• This may be repeated Unstable
every 3-5 min up to a
max of 3mg
Give Atropine
Bradycardia (with Pulse)
HR < 50/min
Algorithm

If atropine is ineffective:
• Turn on the Monitor Unstable
Defibrillator
• Select lead II
• Place the electrodes Give Atropine
• Make sure the pacer is
in Demand mode.
Trancutaneous
Pacing
Bradycardia (with Pulse)
HR < 50/min
Algorithm
• Set the rate at 70-80
• Set current strength at
Unstable
40-60 mA
• Watch the monitor for
electrical capture.
• Now check the pulse Give Atropine

• Once the TCP is noted


to be working , give Trancutaneous
Pacing
sedation
Bradycardia (with Pulse)
HR < 50/min
Algorithm

If the TCP does not achieve


electrical capture: Unstable

• increase the amps


stepwise upto 200mA.
Give Atropine

Trancutaneous
Pacing
Bradycardia (with Pulse)
HR < 50/min
Algorithm

No capture:
• Switch the pacemaker Unstable

to non-demand mode,
where it fires at a set
interval regardless of Give Atropine
intrinsic rhythm.
Trancutaneous
Pacing
Bradycardia (with Pulse) Dopamine/
Algorithm Epinephrine

If TCP fails:
• Start Dopamine at 2-10
micrograms/kg/minute

OR

• Start Epinephrine at 2-10


micrograms per minute
Bradycardia (with Pulse) Dopamine/
Algorithm Epinephrine

• Make preparations for Consider:


transvenous pacing • Expert
Consultation
• TCP should not be used • Transvenous
for more than 6 hours pacing
Tachycardia (with Pulse)
HR > 150/min
Algorithm
Attach:
• Oxygen by simple face
mask
• start an IV line
• hook up a NIBP
• connect a pulse
oximeter
• remember to listen to
the heart and lungs
Tachycardia (with Pulse)
HR > 150/min
Algorithm

• chest pain
• shortness of breath Unstable
• hypotension
• altered mental status
• shock
• pulmonary edema
Tachycardia (with Pulse)
HR > 150/min
Algorithm
Attach the Defibrillator:
• Press the SYNC button
• Defibrillator should be Unstable
flagging the R waves
• Start with an energy
setting of 100 joules Synchronized
Cardioversion
• Press the shock button
• After each shock , do a
pulse check.
Tachycardia (with Pulse)
HR > 150/min
Algorithm

• If 100 Joules did not


work, escalate to 200
Unstable
joules, and then to 300
joules.
Consider Sedation: Synchronized
• Conscious sedation with Cardioversion
Valium 5mg can be given
Tachycardia (with Pulse)
HR > 150/min
Algorithm

If regular narrow complex,


consider:
Unstable
First dose: Adenosine 6mg
rapid IV push; follow with
NS flush Synchronized
Second dose: 12 mg Cardioversion
Tachycardia (with Pulse)
HR > 150/min
Algorithm
• Identify if the QRS
complexes are narrow or
Stable
wide
Normal Duration:
.04-.12 sec
1-3 small boxes
Tachycardia (with Pulse)
HR > 150/min
Algorithm
• Try vagal Maneuvers:
Carotid sinus massage
Valsalva Maneuver
Stable
• If it fails, administer
Adenosine 6mg IV
• If it fails, administer
Adenosine 12mg IV Narrow QRS
• If it fails, use diltiazem 15 Regular Rhythm
mg IV
• If it fails, use diltiazem 25
mg IV, after 15 min
Tachycardia (with Pulse)
HR > 150/min
Algorithm
• Administer Diltiazem 15
mg IV
• Second dose: after 15 Stable

min, 15 mg

Narrow QRS
Irregular rhythm
Tachycardia (with Pulse)
HR > 150/min
Algorithm
• Administer Adenosine
First dose: Adenosine 6mg
rapid IV push; follow with Stable
NS flush
Second dose: 12 mg

Wide QRS
Regular Rhythm
Monomorphic
Tachycardia (with Pulse)
HR > 150/min
Algorithm
• Administer Amiodarone IV
dose
• First dose: 150 mg over 10
Stable
min, follow by maintenance
infusion of 1mg/min for first
6 hours
Wide QRS
Irregular Rhythm
Polymorphic
Tachycardia (with Pulse)
HR > 150/min
Algorithm
• Administer Magnesium 2gm
IV
Stable

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