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.
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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
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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
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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).
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.
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
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.
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
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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.
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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..
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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.
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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*
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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
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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)
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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
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