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ACLS Algorithm's

Identification of Cardiopulmonary Arrest and Initial Patient Assessment

Begin assessment and management of the unconscious victim with the ABCs of Basic Life Support (Airway, Breathing, and Circulation).

BLS

1. Establish unresponsiveness.
2. Call for help. Activate the EMS system.
3. Position the victim and open the Airway.
4. Check for the existence and adequacy of spontaneous Breathing.
5. Perform rescue breathing if needed. Start with two full breaths.
6. Assess Circulation by establishing whether a pulse is present.
7. If pulseless, consider precordial thump. Begin external chest compression, combined with rescue breathing.

If AED available.

Identify prevailing mechanism of the arrest. If not possible follow Ventricular Fibrillation Algorithm.

Ventricular Fibrillation

Initiate Management Sequence for Treatment of Ventricular Fibrillation

1. Initial Defibrillation Series
   1. 1st Counter shock- Use 200 joules
      1. Reassess the patient.
      2. If patient is converted out of Ventricular Fibrillation.
      3. If pulselessness persists, continue CPR while recharging the defibrillator. Minimize time between counter shock.
   2. 2nd Counter shock- Use 300 joules
      1. Reassess the patient.
      2. If patient is converted out of Ventricular Fibrillation.
      3. If pulselessness persists, continue CPR while recharging the defibrillator. Minimize time between counter shock.
   3. 3rd Counter shock- 360 joules
      1. Reassess the patient.
      2. If patient is converted out of Ventricular Fibrillation.
      3. If pulselessness persists, continue CPR, if not already done apply monitoring leads.

   If Ventricular Fibrillation Persists Continue CPR
   

2. Intubate the patient. Establish IV access.
3. EPINEPHRIN
   1. Initially consider SDE(ie. 1 mg IV or ET).
   2. Rapidly increase dose to HDE if the patient fails to respond.
   3. If out-of-hospital cardiac arrest or the period of unresponsiveness is likely to be prolonged use HDE sooner
4. Counter shock- Use 360 joules. If patient is converted out of Ventricular Fibrillation
   If Ventricular Fibrillation Persists continue CPR.
5. LIDOCAINE (Antifibrillatory Therapy).
   1. Give 50-100 mg IV bolus. Circulate with CPR.
   2. Consider starting IV infusion at 2 mg/min.
6. Counter shock- Use 360 joules. If patient is converted out of Ventricular Fibrillation.
7. Search for potentially correctable cause of Ventricular Fibrillation. If patient is converted out of Ventricular Fibrillation.
   If Ventricular Fibrillation Persists continue with CPR.
8. Continue epinephrine (Use HDE).
9. Consider Sodium Bicarbonate.
10. Consider a second (50-75 mg) IV bolus of Lidocaine.
11. Repeat counter shock (with 200-360 joules) as needed. If patient is converted out of Ventricular Fibrillation.
    If Ventricular Fibrillation Persists continue with CPR.
12. Continue epinephrine.
13. Repeat counter shock (with 200-360 joules) as needed. If patient is converted out of Ventricular Fibrillation.
14. Consider additional Antifibrillatory Measures. If patient is converted out of Ventricular Fibrillation.

Patient Converted out of Ventricular Fibrillation

1. Clinically reassess patient's hemodynamic status.
2. Determine the post-conversion rhythm. Treat further according to appropriate algorithm.
   1. Ventricular Tachycardia
   2. Brady arrhythmias
   3. Supraventricular Tachyarrhythmias
3. If not already done, administer bolus of LIDOCAINE (50-100 mg), and begin IV infusion at 2 mg/min.

Ventricular Tachycardia

Identification of Sustained Ventricular Tachycardia and Assessment of hemodynamic status

If there is NO PULSE.

1. DEFIBRILLATION.
   1. Pulseless VT should generally be treated the same as Ventricular Fibrillation- with unsynchronized counter shock. Use 200 joules initially.

If there is a PULSE.

1. If patient is or becomes hemodynamically UNSTABLE.
   1. SYNCHRONIZED CARDIOVERSION.
      1. Immediately cardiovert. Use 100-200 joules.
2. If patient is hemodynamically STABLE.
   1. LIDOCAINE
      1. Give 50-100 mg IV bolus.
      2. Begin infusion at 2 mg/min.
      3. Repeat (50-75 mg) IV boluses (up to a maximum total loading dose of 225 mg).
   2. PROCAINAMIDE
      1. Give 100 mg IV q 5 min (up to 1 g loading dose).
      2. Alternatively, may load patient with 500-1,000 mg (mixed in 100 ml of D5W), to infuse over 30-60 min.
      3. If IV loading is effective, may start a maintenance infusion at 2 mg/min.

      If hemodynamically stable Ventricular Tachycardia persists

   3. BRETYLIUM
      1. IV infusion of 500 mg (mixed in 50 ml of D5W) given over a 10 minute period.
      2. If IV loading is effective, may start a maintenance infusion at 1 - 2 mg/min.
   4. SYNCHRONIZED CARDIOVERSION
      1. Semielective cardioversion- sedate the patient, consider energy level (of 50-100 joules) for initial cardioversion attempt.
   5. ALTERNATIVE MEASURES
      1. Search for potentially correctable cause of sustained Ventricular Tachycardia.
      2. Consider use of an IV Beta-blocker such as propranolol (0.5-1.0 mg by slow IV over 5 minutes- up to a total dose of 5.0 mg).
      3. Magnesium sulfate- 1 - 2 g IV (over 1 - 2 min). May repeat dose in 5 - 10 minutes if there is no response.

Automatic External Defibrillator

AED available.

1. Patient is pulseless- ACLS cannot yet be provided.
   1. One Rescuer.
      1. Do not do CPR.
      2. Immediately activate AED- Power on, attach cables.
   2. More than one Rescuer.
      1. Extra rescuer performs CPR.
      2. Initial rescuer activates AED- Power on, attach cables
2. Analyze rhythm.
   1. No Shock Indicated- Patient not in Ventricular Fibrillation.
      1. Perform CPR for 1 minute.
      2. Recheck Pulse.
      3. If patient has pulse, ACLS can now be provided.
      4. If patient is pulseless, Reanalyze rhythm.
   2. Shock Advised- Patient in Ventricular Fibrillation.
      1. Defibrillate (1st Counter shock), reanalyze rhythm. (Pulse check not needed)
      2. Shock still advised, Defibrillate (2nd Counter shock), reanalyze rhythm. (Again pulse check not needed)
      3. Shock still advised, Defibrillate (3rd Counter shock)
         After series of 3 consecutive shocks is completed.
      4. Recheck pulse.
      5. If patient has pulse, ACLS can now be provided.
      6. If patient still pulseless, perform CPR for 1 minute. Reanalyze rhythm.

Brady arrhythmias including EMD and Asystole

1. CPR
2. EPINEPHRINE
   1. Initially consider SDE (1 mg by IV or ET).
   2. Rapidly increase dose to HDE if patient fails to respond.
3. ATROPINE
   1. 1 mg IV. May repeat X1
4. Pacemaker therapy
   1. External pacer- ASAP
   2. Transvenous pacer when and if available.
5. Consider Sodium Bicarbonate.

1. With a Pulse.
   1. BP Adequate.
      1. Observe.
   2. BP Inadequate.
      1. ATROPINE- 0.5 mg IV q 5 min (up to 2 mg).
      2. DOPAMINE- Begin IV infusion at 2-5 ug/kg/min, and increase as needed.
      3. Volume infusion (if clinically indicated).
2. Without a Pulse (ie, EMD).
   1. CPR.
   2. EPINEPHRINE
      1. Initially consider SDE (1 mg by IV or ET).
      2. Rapidly increase dose to HDE if patient fails to respond.
   3. Look for potentially reversible cause.
   4. Additional considerations.
      1. Fluid challenge
      2. Atropine (if the heart rate is slow)
      3. Sodium bicarbonate

1. With a Pulse
   1. BP Adequate
      1. Observe if
         1. 1st degree AV Block
         2. Mobitz I 2nd degree AV Block
      2. Pacemaker needed if
         1. Mobitz II 2nd degree AV Block
         2. 3rd degree AV Block
         3. Slow IVR
   2. BP Inadequate
      1. CPR (if clinically indicated)
      2. ATROPINE- 0.5-1 mg IV (up to 2 mg)
      3. Pacemaker therapy
         1. External pacer- ASAP
         2. Transvenous pacer when and if available.
      4. Temporizing therapy if pacemaker unavailable and rhythm resistant to atropine. Use pressor agent of your choice until pacing is available.
         1. Dopamine- Begin IV infusion at 2-5 ug/kg/min, and increase as needed.
         2. Epinephrine infusion- Begin with SDE. Rapidly increase to HDE if patient fails to respond.
         3. Isoproterenol- Begin IV infusion at 2 ug/min, and increase as needed.
2. Without a Pulse (ie, EMD).
   1. CPR.
   2. EPINEPHRINE
      1. Initially consider SDE (1 mg by IV or ET).
      2. Rapidly increase dose to HDE if patient fails to respond.
   3. Look for potentially reversible cause.
   4. Additional considerations.
      1. Fluid challenge
      2. Atropine (if the heart rate is slow)
      3. Sodium bicarbonate

Supraventricular Tachyarrhythmias

Identification of SVT/Assessment of hemodynamic status

1. Synchronized Cardioversion
   1. Immediately cardiovert. Use 100-200 joules.

1. Obtain a 12-lead ECG.
2. Diagnose the Mechanism of the arrhythmia- Be sure rhythm is supraventricular and not VT.
   1. Sinus Tachycardia
   2. Paroxysmal Supraventricular Tachycardia (PSVT)
   3. Multi focal Atrial Tachycardia (MAT)
   4. Atrial Fibrillation or Atrial Flutter

1. Identification and treatment of underlying cause.

1. Vagel maneuver
2. Medication
   1. VERAPAMIL
      1. 3-5 mg IV initially.
      2. May give 5-10 mg IV (15-30 min later) if no response.
      3. Consider repeating vagel maneuver.
      4. Consider calcium pretreatment (especially if BP is low).
   2. ADENOSINE
      1. 6 mg IV push. Follow with saline flush
      2. If no response in 1-2 minutes, give 12 mg by IV push.
      3. May follow with final 12 mg IV push.
3. Sedation- May be helpful.
4. Other Measures (only rarely needed).
   1. DIGOXIN
   2. IV Beta-Blocker
   3. Synchronized Cardioversion.

1. Treat underlying cause (ie, hypoxia).
2. VERAPAMIL
   1. 3-5 mg IV initially
   2. Then 5-10 mg

1. Controlled Ventricular Response
   1. Observe (No specific treatment needed on an emergency basis).
2. Rapid Ventricular Response.
   1. DIGOXIN
      1. Load with 0.25-0.5 mg IV
      2. Then 0.125-0.25 mg IV g 2-6 hrs (as needed up to 0.75-1.5 mg total).
   2. VERAPAMIL
      1. 3-5 mg IV initially
      2. Then 5-10 mg
   3. IV Beta-Blocker (Should not be given in close proximity to IV verapamil)
      1. Propranolol- 0.5-1 mg by slow IV (over 5 minutes) up to a total of 5 mg.
      2. Esmolol
   4. Synchronized Cardioversion
      1. Use at least 200 joules for Atrial Fibrillation.
      2. Use 20-50 joules for Atrial Flutter.