ACLS

ALGORITHMS

Acute Pulmonary Edema / Hypotension / Shock Algorithm

Volume problemIncludes PVR problems

Systolic BP < 70Signs of shock

Administer• Fluids• Blood transfusions• Cause-specific interventions• Consider vasopressors

Too SlowGo to Fig 5

Rate ProblemPump Problem

Systolic BP 70 - 100 mmHgSigns of shock

Too FastGo to Fig 6

Systolic BP> 100 mmHg

Systolic BP70 - 100 mmHgNo Signs of shock

Clinical signs of hypoperfusion, congestive heart failure, acute pulmonary edemaAssess ABC’s Assess vitalsSecure airway Review historyAdminister O2 Perform physical examStart IV 12 lead ECG, chest x-rayAttach 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 ABC’s Assess vitalsSecure airway Review historyAdminister O2 Perform physical examStart IV 12 lead ECG, chest x-rayAttach 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 blockor

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 ABC’s Assess vitalsSecure airway Review historyAdminister O2 Perform physical examStart IV 12 lead ECG, chest x-rayAttach monitor, pulse oximetry and B/P Cuff

If ventricular rate > 150 BPM• Prepare for cardioversion• May give brief trial of Rx • Immediate cardioversion is seldom needed for heart rates < 150 BPM

Wide-complextachycardia of uncertain type

VentricularTachycardia (VT)

ParoxysmalSupraventricularTachycardia(PSVT)

Atrial FibrillationAtrial 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 CO2, echocardiography, or arterial line

Consider possible causesHypovolemia (volume infusion) Drug overdoses - tricyclics, digitalisHypoxia (ventilation) Beta-blockers, calcium channel blockersCardiac tamponade (pericardiocentesis) HyperkalemiaTension Pneumothorax AcidosisHypothermia ( see hypothermia algorithm) Massive acute myocardial infarctionMassive 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/kgd,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 immediatetranscutaneous 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/VT200 J, 200 - 300 J, 360 J

Rhythm after the first 3 shocks? b

AsystoleGo to Fig 4

PEAGo to Fig 3

VF/VT ROSC

Figure 2

• Continue CPR• Intubate / IV Access

VF & Pulseless VT

Defibrillate 360 J, 30 - 60 sec after Rx

Epinephrine c,d 1 mg/IV

2 mg/ETT q 3 - 5 min

Administer Rx Class IIaprobable benefit f, g

Defibrillate 360 Jwithin 30 - 60 sec

Figure 2