Download - ACLS algorithms

Cardiac ArrestCircular Algorithm

2 minutes

Drug Therapyaccess

If VF/VTShock

Shout for Help/Activate Emergency Response

Doses/Details for the Cardiac Arrest Algorithms

Drug Therapy

Return of Spontaneous Circulation (ROSC)

- Hypovolemia- Hypoxia - Hydrogen ion (acidosis) - Hypo-/Hyperkalemia- Hypothermia

- Tension pneumothorax- Tamponade, cardiac- Toxins - Thrombosis, pulmonary- Thrombosis, coronary

CPR Quality

Advanced Airway*** Supraglottic advanced airway or endotracheal intubationWaveform capnography to confirm and monitor ET tube placement8-10 breaths per minute with continuous chest compressions

Epinephrine IV/IO Dose: 1 mg every 3-5 minutes Vasopressin IV/IO Dose: 40 units can replace first or second dose of epinephrine Amiodarone IV/IO Dose**:First dose: 300 mg bolus. second dose: 150 mg

Reversible Causes

Shock Energy Biphasic: Manufacturer recommendation (eg, initial dose of 120-200 J): if unknown, use maximum available.Second and subsequent doses should be equivalent, and higher doses may be consideredMonophasic: 360 J

CPR

START

Push hard ( 2 inches [5cm]) and fast ( 100/min) and allow complete chest recoil.Minimize interruptions in compressions.*Avoid excessive ventilationRotate compressor every 2 minutesIf no advanced airway, 30:2 compression-ventilation ratioQuantitative waveform capnographyIf PETCO2 10mm Hg, attempt to improve CPR quality Intra-arterial pressure If relaxation phase (diastolic) pressure 20 mm Hg, attempt to improve CPR quality.

Pulse and blood pressureAbrupt sustained increase in PETCO2 (typically 40 mm Hg)Spontaneous arterial pressure waves with intra-arterial monitoring

Post-CardiacArrest Care

Circulation (ROSC)Return of Spontaneous

CheckRhythm

Attach Monitor/DefibrillatorGive Oxygen

Epinephrine every 3-5 minutesAmiodarone for refractory VF / VT

Consider Advanced Airway

Quantitative waveform capnography

Treat Reversible Causes

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IV/IO

Epinephrine every 3-5 minConsider advanced airway,

capnography

AmiodaroneTreat reversible causes

Start CP... R

Cardiac ArrestAlgorithm

YES

Shock*

Asystole/ PEA

Treat reversible causes

NO

NO

YES

Attach Monitor/DefibrillatorGive Oxygen

Shout for Help/Activate Emergency Response

Rhythm Shockable?

Rhythm Shockable?

Shock

Rhythm Shockable?

Rhythm Shockable?

Rhythm Shockable?

Shock

Go to 5 or 7

If ROSC, go to Post-Cardiac Arrest Care.

2

3

4

5

6

7

8

9

10

11

12

VF/VT

1

Y N

YY

N

N

YY

N

N

Y

YY

CPR 2 min

CPR 2 min CPR 2 min

CPR 2 min IV/IO accessEpinephrine every 3-5 minConsider advanced airway, capnography

IV/IO access

If no signs of return ofspontaneous circulation(ROSC), go to 10 or 11.



CPR 2 min

(c)

Symptoms Suggestive of Ischemia or Infarction

Oxygen(If O sat < 94%)2

Aspirin160 - 325 mg

FibrinolyticChecklist

CheckContraindications

Cardiac MarkerLevels

Chest X-ray(<30 mins)

Check VitalSigns

IV Access PhysicalExam

FibrinolyticChecklist

ID

TnlCK-MB

MYO

PainControl

Aspirin160 - 325 mg(If not already taken)

If O sat <94%Start Oxygen

2

High-risk unstable angina/non-ST-elevationMI (UA/NSTEMI)Start adjunctive therapies

as indicatedDo not delay reperfusion

Consider admission to ED chest pain unitor to appropriate bed and follow:

heparin, and other therapies as indicated If no evidence of ischemia orinfarction by testing, candischarge with follow-up

N

N

Low-/Intermediate-risk ACS

Troponin elevated or high-risk patientConsider early invasive strategy if:

Refractory ischemic chest discomfort

Ventricular tachycardiaHemodynamic instabilitySigns of heart failure

Recurrent/persistent ST deviation

Start adjunctive treatments as indicated

Develops 1 or more:• Clinical high-risk features• Dynamic ECG changesconsistent with ischemia

• Troponin elevated

Time from onsetof symptoms

12 hours?

Serial cardiac markers (including troponin)Repeat ECG/continuous ST-segment monitoringConsider noninvasive diagnostic test

Reperfusion goals:

Y

Y

Not at high risk: cardiology to risk stratifyACE inhibitor/ARB; HMG CoA reductase inhibitor (statin therapy)

NitroglycerinHeparin (UFH or LMWH)Consider: PO -blockersConsider: ClopidogrelConsider: Glycoprotein

Abnormal diagnosticnoninvasive imaging or

physiologic testing?

Acute CoronarySyndromes Algorithm

ACLS Training Center 877-560-2940 [email protected]

12

>12

hours

hours

Nitroglycerinsublingual or

spray

PainControl

(c)

EMS assessment and care and hospitalpreparation*

Immediate ED general treatment

Concurrent ED assessment

( 10 minutes)

12-Lead ECG

12-Lead ECG

ECG Interpretation*

llb/llla inhibitor

Admit to monitored bed Assess risk status Continue ASA

ST-elevation MI (STEMI)

Door-to-balloon inflation (PCI)**goal of 90 minutesDoor-to-needle (fibrinolysis)goal of 30 minutes


Pulseless Arrest Algorithm for Managing Asystole

Using the Pulseless Arrest Algorithm forManaging Asystole

Version control: This document is current with respect to drug indications in 2010 American HeartAssociation Guidelines for CPR and ECC. These guidelines are current until they are replaced onMarch 2016. If you are reading this page (printed or online) after March 2016, please contact ACLSTraining Center at [email protected] for an updated document.

Management of a patient in cardiac arrest with asystole follows the same pathway as management ofPEA. The top priorities stay the same: Following the steps in the ACLS Pulseless Arrest Algorithm andidentifying and correcting any treatable, underlying causes for the asystole. The algorithm assumes thatscene safety has been assured, personal protective equipment is being used, and no signs of obviousdeath are present.

Begin with the primary survey to assess the patient'scondition:

In the absence of respirations and a pulse in the presence of asystole (present in two leads)consideration of termination of efforts should take place

Follow the ACLS Pulseless Arrest Algorithm for asystole:Check the patient's rhythm, taking less than 10 seconds to assess.

Verify the presence of asystole in at least two leads

Resume CPR at a rate of at least 100/minute. Rotate team members every 2 minutes with rhythmbreaks to help maintain high quality CPR.

As soon as IV or IO access is available, administer epinephrine 1mg IV/IO. Do not stop CPR toadminister drugs.

During CPR, search for and treat possible contributing causes (H's and T's in Figure 1).

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Check rhythm.

If no electrical activity is present (patient is in asystole), resume CPR.

If electrical activity is present, see if the patient has a pulse.

If the patient does not have a pulse or there is some doubt about the pulse, resume CPR.

If a good pulse is present and the rhythm is organized, begin postresuscitative care.

IV/IO access is a priority over advanced airway management. If an advanced airway is placed, change tocontinuous chest compressions without pauses for breaths. Give 8 to 10 breaths per minute and checkrhythm every 2 minutes.

Without a pulse or electrical activity on the ECG, the emergency care team needs to decide whenresuscitation efforts should stop. The patient's wishes and the family's concerns need to be considered.

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Pulseless Arrest Algorithm for ManagingPulseless Electrical Activity (PEA)

Using the Pulseless Arrest Algorithm for Managing PEA

Version control: This document is current with respect to drug indications in 2010 American HeartAssociation Guidelines for CPR and ECC. These guidelines are current until they are replaced onMarch 2016. If you are reading this page (printed or online) after March 2016, please contact ACLSTraining Center at [email protected] for an updated document.

Patients with PEA have poor outcomes. Their best chance of returning to a perfusing rhythm is throughthe quick identification of an underlying reversible cause and correct treatment. As you use the algorithmto manage the PEA patient, remember to consider all the H's and T's, particularly hypovolemia, which isthe most common cause of PEA. Also look for drug overdoses or poisonings.

Begin with the primary survey to assess the patient'scondition:

1. Pulseless Electrical Activity (PEA) occurs when you see a rhythm on the monitor that wouldnormally be associated with a pulse, however the patient is pulses.

2. The rhythm can be anything, at any heart rate

3. There is something preventing the heart from generating a pulse, such as being empty(Hypovolemia) something pushing against it (Tamponate)

4. Reassess the patient frequently for the return of pulses

Follow the ACLS Pulseless Arrest Algorithm1. Begin CPR as soon as pulselessness is recognized. Continue CPR at a rate of 100/min throughout

the resuscitation without interuptions of more than 10 seconds to evaluate for pulses.

2. Compressors should be switched every 2 minutes to ensure efficacy of compressions

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3. Waveform capnography should be utilized to monitor efficacy of compressions (should generate atleast 10) and the return of pulses (will cause an increase in capnography to 40)

4. Obtain IV/IO access

5. Administer Epinephrine 1 mg IV/IO every 35 minutes

6. Find and treat underlying causes.

Two management priorities are maintaining high quality CPR and searching simultaneously for atreatable cause of the patient's PEA. Stop CPR only when absolutely necessary for pulse and rhythmchecks. Establishing IV/IO access is a priority over advanced airway management. If an advanced airwayis placed, change to continuous chest compressions without pauses for breaths. Give 8 to 10 breathsper minute and check rhythm every 2 minutes.

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Ventilation/Oxygenation

IV Bolus

Epinephrine IVInfusion

Dopamine IVInfusion

NorepinephrineIV InfusionReversible Causes

IV/IO bolus Vasopressor infusionConsider treatable causes

Immediate Post-Cardiac

Arrest Care Algorithm

Follow Commands? N

Y

STEMI or High Suspicion of AMI

Advanced Critical Care

Consider Induced Hypothermia**

Y

Coronary Reperfusion***

N



Return of Spontaneous Circulation (ROSC)*

Maintain oxygen saturation ≥ 94%

Consider advanced airway

waveform capnography

Do not hyperventilate

Treat Hypotension (SBP < 90 mm Hg) Optimize Ventilation and

Oxygenation

12-Lead ECG

Doses/Details

Avoid excessive ventilation.

Start at 10-12 ≥ 94% breaths/min

and titrate to target PETCO2

of 35-40 mm Hg.

When feasible, titrate FIO2

to minimum necessary to

achieve SpO2 94%.

1-2 L normal saline or

lactated Ringer’s.If inducing hypothermia, may use 4 C fluid.

0.1-0.5 mcg/kg per minute(in 70-kg adult: 7-35 mcg

per minute)

- Hypovolemia

- Hypoxia

- Hydrogen ion (acidosis)

- Hypo-/Hyperkalemia

- Hypothermia- Tension pneumothorax

- Tamponade, cardiac

- Toxins

- Thrombosis, pulmonary

- Thrombosis, coronary

0.1-0.5 mcg/kg per minute(in 70-kg adult: 7-35 mcg

per minute)

5-10 mcg/kg per minute

Identify and treat underlying cause

Monitor and observe

Persistent bradyarrhythmia causing:

Hypotension?

Atropine IV Dose:

First dose: 0.5 mg bolus

Maintain patent airway; assist breathing as necessary *

Cardiac monitor to identify rhythm; monitor blood pressure and oximetry

Acutely altered mental status?Signs of shock?Ischemic chest discomfort?Acute heart failure?

Repeat every 3-5 minutesMaximum: 3 mg

Consider:

Expert consultation

IV access12-Lead ECG if available; don't delay therapy

Bradycardia Witha Pulse Algorithm

If atropine ineffective:

Oxygen (if hypoxemic)

Y

N

Transcutaneous pacing**

OR

Dopamine IV infusion:

2-10 mcg/kg per minute

OR

Epinephrine IV infusion:

2-10 mcg per minute

Transvenous pacing

Assess appropriateness for clinical condition.Heart rate typically 50/min if bradyarrhythmia.



Initial recommended doses:

Doses/Details

Second dose : 12 mg if required

Antiarrhythmic Infusionsfor Stable Wide-QRS

TachycardiaProcainamide IV Dose:

Maintenance infusion : 1-4 mg/min.Avoid if prolonged QT or CHF.

Amiodarone IVDose:

Sotalol IV Dose:

100 mg (1.5 mg/kg ) over 5 minutes.Avoid if prolonged QT.

Assess appropriateness for clinical condition.Heart rate typically > 150/min if tachyarrhythmia.

Maintain patent airway; assist breathing as necessary

Oxygen (if O sat < 94%)

Cardiac monitor to identify rhythm; monitor blood pressure and oximetry

SynchronizedCardioversion*

Consider sedationIf regular narrow complex,

consider adenosine

IV access and 12-lead ECG if available.

Consider antiarrhythmic infusion.

Consider expert consultation.

Vagal Maneuvers.

Adenosine (if regular)

-Blocker or calcium channel blocker.

Consider expert consultation.

Identify and Treat Underlying Cause

SynchronizedCardioversion**

2

Persistent Tachyarrhythmia Causing:

Hypotension?

Acutely altered mental status?

Signs of shock?

Ischemic chest discomfort?

Acute heart failure?

Wide QRS?≥ 0.12 second

Tachycardia With a

Pulse Algorithm

Y

N

Y

N

Consider adenosine only if regular andmonomorphic.

IV access and 12-lead ECG if available.

Narrow irregular : 120-200 Jbiphasic or 200 J monophasic

Narrow regular : 50-100 J

Wide irregular : Defibrillation dose (NOT synchronized )

Wide regular : 100 J

Adenosine IVDose:

First dose : 6 mg rapid IV push; follow with NS flush.

20-50 mg/min until arrhythmiasuppressed, hypotension ensues,QRS duration increases 50% ormaximum dose 17 mg/kg given.

First dose : 150 mg over 10 minutes.Repeat as needed if VT recurs.Follow by maintenance infusionof 1 mg/min for first 6 hours..



Abnormal Speech (have the patient say “you can’t teach an old dog new tricks”)

Both sides of face move equally.

NORMAL ABNORMAL

Both arms move the same orboth arms do not move at all.

The Cincinnati Prehospital Stroke Scale

(patient closes eyes and extends both arms straight out, with palms up for 10 seconds)

Facial Droop(have patient show teeth or smile)

One arm does not move or one arm drifts down compared with the other.

NORMAL ABNORMAL

Abnormal - Patient slurs words, uses the wrong words, or is unable to speak.

Arm Drift

Normal - Patient uses correct words with no slurring.

If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%

Stroke Assessment

One side of face does not move as well as the other side.



Administer aspirin

Critical EMS assessments and actions

Obtain 12-lead ECG

Assess ABCs, vital signsProvide oxygen if O2 sat < 94%Obtain IV access and perform laboratory assessmentsCheck glucose; treat if indicated

Perform neurologic screening assessmentOrder emergent CT or MRI of brain

Does CT Scan Show Hemorrhage?

Begin post-rtPA stroke pathwayAggressively monitor:- BP per protocol- For neurologic deteriorationEmergent admission to strokeunit or intensive care unit

Review risks/benefits withpatient & family. If acceptable:

treatment for 24 hours

Immediate general assessment and stabilization*

Immediate neurologic assessment by stroke team or designee

No Hemorrhage Hemorrhage

Consult neurologist or neurosurgeon; consider transfer if not available.

Identify Signs and Symptoms of Possible StrokeActivate Emergency Response

Performprehospital stroke

assessment

Establish timeof symptom

onset (last normal)

Triage tostroke centre

Alert hospitalCheck glucoseSupport ABCs:Give Oxygen

if needed

Give rtPA** No anticoagulants or antiplatelet

Probable acute ischemic stroke; consider fibrinolytic therapy

Goals for Management of Stroke

Suspected Stroke Algorithm:

Activate stroketeam

Review patient historyEstablish time of symptom onset or last known normalPerform neurologic examination (NIH Stroke Scale or Canadian Neurological Scale)

Begin stroke or hemorrhage pathwayAdmit to stroke unit orintensive care unit

Check for fibrinolytic exclusionsRepeat neurologic exam: are deficitsrapidly improving to normal?

Patient remains candidatefor fibrinolytic therapy?

Not a Candidate

Candidate*



NINDSTIME

GOALS

Within 10 min

of ED Arrival

Within 25 min

of ED Arrival

Within 45 min

of ED Arrival

Within 60 min

of ED Arrival

StrokeAdmission

within3 hours

STOP

YES

YES

NO

NO

Are there contraindications to fibrinolysis? If ANY one of the following is checked YES, fibrinolysis MAY be contraindicated. **

FibrinolyticChecklist for STEMI*

Heart rate >100/min AND systolic BP < 100 mm Hg

YES NO

Pulmonary edema (rales)

Signs of shock (cool, clammy)

Required CPR

Systolic BP >180 to 200 mm Hg or diastolic BP > 100 to 110 mm Hg

Right vs left arm systolic BP difference > 15 mm Hg

History of structural central nervous system disease

Stroke >3 hours or <3 months

Recent (within 2-4 weeks) major trauma, surgery (including laser eyesurgery), GI/GU bleed

Bleeding, clotting problem, or blood thinners

Pregnant female

Serious systemic disease (eg, advanced cancer, severe liver orkidney disease)

YES NO

***

Does ECG show STEMI or new or presumably new LBBB?

Has patient experienced chest discomfort for greater than 15 minutes and less than 12 hours?

Is patient at high risk? If ANY one of the followingis checked YES, consider transfer to PCI facility.

Significant closed head/facial trauma within the previous 3 months

Any history of intracranial hemorrhage

Contraindications to fibrinolytic therapy

Infarction (STEMI)” at Agency for Healthcare Research and Quality National Guideline Clearinghouse (www.Guidelines.gov). *** Consider transport to primary PCI facility as destination hospital.

** Contraindications for fibrinolytic use in STEMI consistent with “Thrombolytic Therapy and Balloon Angioplasty in Acute ST Elevation Myocardial



FibrinolyticTherapy for STEMI

Contraindications for fibrinolytic use in STEMI consistent with ACC/AHA 2007 Focused Update*

Any prior intracranial hemorrhage

Known malignant intracranial neoplasm (primary or metastatic)

Ischemic stroke within 3 months EXCEPT acute ischemic strokewithin 3 hoursSuspected aortic dissection

Active bleeding or bleeding diathesis (excluding menses)

History of chronic, severe, poorly controlled hypertension

Severe uncontrolled hypertension on presentation (SBP >180 mmHg or DBP >110 mm Hg) ***History of prior ischemic stroke >3 months, dementia, or knownintracranial pathology not covered in contraindications Traumatic or prolonged (>10 minutes) CPR or major surgery(< 3 weeks) Recent (within 2 to 4 weeks) internal bleeding

Noncompressible vascular punctures

For streptokinase/anistreplase: prior exposure (>5 days ago) orprior allergic reaction to these agentsPregnancy

Active peptic ulcer

Current use of anticoagulants: the higher the INR, the higher therisk of bleeding

Absolute Contraindications**

Relative Contraindications

Significant closed head trauma or facial trauma within 3 months

Known structural cerebral vascular lesion (eg, arteriovenous malformation)



ALS Pharmacology SummaryDrugs indicated for use in Advanced Life Support cases[1]

Adenosine(Adenocard)

15-30°C (59-86°F)Do not refrigerate

Amiodarone(Cordarone)

20-25°C (68-77°F)Protect from light

Atropine Sulfate(Hospira Inc.)

20-25°C (68-77°F)

Dopamine(Dopamine HCl)

20-25°C (68-77°F)Avoid excessive heat. Protect from freezing.

Epinephrine(EpiPen)

20-25°C (68-77°F)Protect from light. Do not refrigerate.

Lidocaine(Xylocaine-MPF)

20-25°C (68-77°F)Protect from light.

Magnesium Sulfate(Ansyr)[3]

20-25°C (68-77°F)

Vasopressin(Desmopressin Acetate)

20-25°C (68-77°F)

Drug Storage[3]

Saline(0.9% NaCl)[1]

25°C (77°F)Administer 4°C (39°F) for therapeutic hypothermia